A 76-year-old client with heart failure is admitted with acute confusion, muscle weakness, and a serum sodium level of 118 mEq/L. What is the nurse’s priority intervention?
Obtain the client’s daily weight
Initiate seizure precautions
Encourage consumption of a high-sodium diet
Administer hypotonic intravenous fluids
The correct answer is to initiate seizure precautions because a serum sodium level of 118 mEq/L indicates severe hyponatremia, which places the client at high risk of neurological complications, including seizures. Hypotonic fluids would worsen the sodium level and are contraindicated. While a daily weight is helpful to evaluate fluid status, it does not address the immediate risk associated with neurological complications. A high-sodium diet may be part of a long-term treatment plan, but it is not an immediate priority.
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