A client is being treated for acute pyelonephritis and will undergo laboratory tests. These tests are expected to help determine the clients BUN, creatinine, and serum electrolyte levels. Why should the nurse evaluate these test results?

Correct Answer: D

Rationale: The correct answer is D: To determine clients response to therapy. Evaluating BUN, creatinine, and serum electrolyte levels in a client being treated for acute pyelonephritis helps the nurse assess the effectiveness of the therapy. Changes in these levels indicate how well the kidneys are functioning and how the client is responding to treatment. Monitoring these parameters allows for adjustments in therapy if needed. Incorrect choices: A: To determine the severity of the disorder - While these tests can provide information about the severity of kidney dysfunction, the primary focus is on monitoring the response to therapy. B: To identify signs of fluid retention - While BUN and creatinine levels can indirectly indicate fluid status, the main purpose of evaluating these tests is to assess therapy response. C: To determine the location of discomfort - These tests do not provide information about the location of discomfort but rather focus on kidney function and response to treatment.

Correct Answer: B

Rationale: The correct answer is B because encouraging the intake of low-sodium liquids like coffee or tea can worsen hyponatremia. Hyponatremia is a condition characterized by low sodium levels in the blood, so encouraging low-sodium liquids would further dilute the sodium levels. The other choices are correct interventions for hyponatremia: A) assessing for symptoms helps in monitoring the patient's condition, C) monitoring neurological status is crucial as hyponatremia can lead to neurological complications, and D) restricting tap water intake helps in managing fluid intake and preventing further dilution of sodium levels.

Correct Answer: D

Rationale: The correct answer is D: Hypocalcemia. Severe diarrhea can lead to electrolyte imbalances, including low calcium levels. Decreased muscle tone and deep tendon reflexes are classic signs of hypocalcemia. Calcium is essential for proper muscle function and nerve transmission. Hypernatremia (A) is high sodium levels, not related to decreased muscle tone. Hyperchloremia (B) is high chloride levels, not associated with muscle tone changes. Hypokalemia (C) is low potassium levels, which can cause muscle weakness but not specifically decreased muscle tone and deep tendon reflexes like hypocalcemia.

Correct Answer: A

Rationale: The correct answer is A: New set of tracheostomy tubes and Oxygen tank. Rationale: 1. New set of tracheostomy tubes: Essential for reinserting the cannulas to secure the airway. 2. Oxygen tank: To ensure James has a stable oxygen supply while the tracheostomy tubes are being reinserted. Summary of incorrect choices: B: Theophylline and Epinephrine - These medications are not directly related to managing a dislodged tracheostomy. C: Obturator and Kelly clamp - While these are useful tools for tracheostomy care, they are not the immediate equipment needed in this emergency situation. D: Sterile saline dressing - This is not relevant for a dislodged tracheostomy; the priority is securing the airway.

Correct Answer: A

Rationale: The correct answer is A: Daily intake and output. Monitoring fluid balance involves tracking the amount of fluids taken in and expelled from the body. Intake includes oral, IV, and tube feedings, while output includes urine, vomitus, diarrhea, and any other fluid losses. Daily intake and output provide a comprehensive view of a patient's fluid status, helping identify trends and potential issues. Vital signs (B) provide general information but not specific to fluid balance. Daily weight (C) can fluctuate due to various factors, not just fluid status. Skin turgor (D) is a late sign of dehydration and not as reliable as intake and output monitoring.