Nursing interventions for a patient with a diagnosis of hyponatremia includes all of the following except:

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: A

Rationale: The correct answer is A: Removal of the transplanted kidney. Hyperacute rejection is a severe and immediate immune response to the transplanted organ. In this case, the transplanted kidney must be removed promptly to prevent further complications, as it is irreversibly damaged. High-dose IV cyclosporine (B) is used for immunosuppression but is not effective in treating hyperacute rejection. Bone marrow transplant (C) is not indicated for kidney rejection. Intra-abdominal instillation of methylprednisolone sodium succinate (D) is used for acute rejection, not hyperacute rejection.

Correct Answer: B

Rationale: The correct answer is B because it follows the SMART approach: Specific (monitor heart rhythm), Measurable (continuously this shift), Achievable (feed self at all mealtimes), Relevant (shortness of breath), and Time-bound (today). Choice A lacks specificity and measurability. Choice C focuses on the nurse's action, not patient outcomes. Choice D lacks specificity and measurability, focusing on the nurse's actions rather than patient outcomes.

Correct Answer: D

Rationale: Step-by-step rationale: 1. A balanced and varied diet provides essential nutrients for immune function. 2. Including a wide range of foods ensures intake of vitamins, minerals, and antioxidants crucial for immune health. 3. Avoiding extremes like excessive immune-enhancing formulas or eliminating polyunsaturated fatty acids maintains balance. 4. Essential fatty acids and omega-3 fatty acids are beneficial but should be part of a well-rounded diet. 5. For clients with immune-mediated disorders, individualized dietary advice may be necessary. Summary: - A: Immune-enhancing formulas may not be necessary and could disrupt balance. - B: Avoiding all polyunsaturated fatty acids is not advisable as some are essential for health. - C: Increasing essential fatty acids is beneficial but should be part of a balanced diet.

Correct Answer: D

Rationale: The correct answer is D: Administer pain medication. The priority in this situation is to address the patient's pain and provide relief. Administering pain medication will help alleviate the discomfort and enable the patient to mobilize with crutches or a walker. Walking without pain is crucial for the patient's recovery. Explanation for other choices: A: Assisting the patient to walk with crutches may worsen the pain and should not be attempted until the pain is managed. B: Obtaining a walker is not the priority as the immediate concern is addressing the patient's pain. C: Consulting physical therapy may be beneficial in the long term, but immediate pain relief is the priority in this situation.

Correct Answer: A

Rationale: Correct Answer: A (Independent intervention) Rationale: 1. Independent interventions are actions that nurses can initiate without a doctor's order. 2. Teaching a client how to administer insulin falls under the scope of nursing practice. 3. Nurses have the knowledge and authority to educate clients on self-care management. 4. This intervention does not require collaboration with other healthcare providers. Summary: B: Dependent interventions require a doctor's order. C: Interdependent interventions involve collaboration with other healthcare providers. D: Collaborative interventions involve working with other healthcare professionals.

Correct Answer: B

Rationale: The correct answer is B because changing habits and customs that predispose the individual to cancer is crucial in preventing cancer. This includes lifestyle changes such as quitting smoking, maintaining a healthy diet, exercising regularly, and avoiding excessive sun exposure. By modifying behaviors that increase cancer risk, individuals can significantly reduce their chances of developing cancer. A: Increasing governmental control of potential carcinogens is not the first step towards effective cancer control as individual behaviors have a more direct impact on cancer risk. C: Conducting more mass screening programs is important but not the first step as prevention through lifestyle changes takes priority. D: Educating the public and professionals about cancer is essential but changing habits is the initial crucial step in effective cancer control.

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: D

Rationale: The correct answer is D, as exercise and a weight reduction diet are essential components in managing type 2 diabetes. Exercise helps lower blood glucose levels and improves insulin sensitivity. Weight reduction reduces insulin resistance. Choice A is incorrect because maintaining blood glucose levels between 180-200mg/dl is too high and can lead to complications. Choice B is incorrect as complete smoking cessation is crucial for overall health and diabetes management. Choice C is incorrect because eye examinations should be done annually, not every 2 years, to monitor for diabetic retinopathy. In summary, choice D is the best option as it directly addresses the management of type 2 diabetes.