A nurse is caring for a client being treated for hypernatremia. Which of the following are appropriate nursing interventions? (SELECT ALL THAT APPLY)

Encourage eating potassium-rich foods.

Restrict sodium in the diet

Decrease water intake

Monitor vital signs

Monitor intake and output.

Answer and Explanation

Correct Answer : B,D,E

Choice A rationale: Hypernatremia involves elevated sodium levels, so encouraging potassium-rich foods is not directly related to addressing hypernatremia.

Choice B rationale: Restricting sodium in the diet is appropriate to help manage and reduce hypernatremia. This can prevent further complications of hypernatremia, such as dehydration, confusion, seizures, and coma.

Choice C rationale: This is not an appropriate intervention for hypernatremia, as water intake can help dilute the sodium levels and restore the fluid balance in the body.

Decreasing water intake can worsen the hypernatremia and cause dehydration. Choice D rationale: This is an appropriate intervention for hypernatremia, as high sodium levels can affect the fluid balance and blood pressure in the body. Monitoring

vital signs can help detect any changes or abnormalities that may indicate worsening of the condition or need for further treatment.

Choice E rationale: Monitoring intake and output helps assess fluid balance and response to interventions for hypernatremia.

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Correct Answer is B

Explanation

Choice A rationale: Ineffective gas exchange is related to respiratory issues but may not be the priority in this case.

Choice B rationale: Ineffective breathing pattern is the priority problem, as evidenced by shallow respirations and reluctance to perform coughing and deep breathing, which can lead to respiratory complications.

Choice C rationale: Activity intolerance is not the priority problem based on the given data.

Choice D rationale: Decreased cardiac function is not the priority problem based on the given data.

A. read previous documentation on the client's chart. B. observe the client at rest and during activity. C. ask if shortness of breath is being experienced. D. auscultate lung sounds.

Correct Answer is B

Explanation

Choice A rationale: Reading previous documentation provides historical information but may not reflect the current level of dyspnea.

Choice B rationale: Observing the client at rest and during activity is the best way to assess the current level of dyspnea.

Choice C rationale: Asking if shortness of breath is being experienced provides subjective information but may not be as reliable as direct observation.

Choice D rationale: Auscultating lung sounds is important for assessing respiratory function but may not provide a comprehensive picture of dyspnea.

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A nurse is caring for a client being treated for hypernatremia. Which of the following are appropriate nursing interventions? (SELECT ALL THAT APPLY)

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