Nokea
A 25-year-old client taking hydroxychloroquine (Plaquenil) for rheumatoid arthritis reports difficulty seeing out of her left eye. Correct interpretation of this assessment finding indicates which of the following?
- A. Development of a cataract.
- B. Possible retinal degeneration.
- C. Part of the disease process.
- D. A coincidental occurrence.
Correct Answer: B
Rationale: Hydroxychloroquine can cause retinal toxicity, leading to vision changes. This is a known side effect requiring immediate medical evaluation.
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What is a key nursing intervention for a client receiving peritoneal dialysis?
- A. Monitor for signs of peritonitis.
- B. Restrict protein intake.
- C. Administer anticoagulants.
- D. Limit ambulation.
Correct Answer: A
Rationale: Peritonitis is a serious complication of peritoneal dialysis, requiring vigilant monitoring.
The nurse is assessing the urine of a client who has had an ileal conduit and notes that the urine is yellow with a moderate amount of mucus. Based on the data, the nurse should?
- A. Change the appliance bag.
- B. Notify the physician.
- C. Obtain a urine specimen for culture.
- D. Encourage a high fluid intake.
Correct Answer: D
Rationale: Yellow urine with moderate mucus is normal for an ileal conduit due to intestinal segment use. Encouraging high fluid intake prevents complications like calculi or infection.
A client with multiple myeloma is admitted with a serum calcium level of 13.2 mg/dL. Which of the following nursing interventions is the priority?
- A. Administer oral calcium supplements.
- B. Encourage ambulation.
- C. Administer I.V. normal saline.
- D. Restrict fluid intake.
Correct Answer: C
Rationale: Hypercalcemia (serum calcium >10.5 mg/dL) in multiple myeloma requires urgent I.V. normal saline to promote calcium excretion and prevent renal damage, making it the priority intervention.
Which of the following health promotion activities should the nurse include in the discharge teaching plan for a client with asthma?
- A. Incorporate physical exercise as tolerated into the daily routine.
- B. Monitor peak flow numbers after meals and at bedtime.
- C. Eliminate stressors in the work and home environment.
- D. Use sedatives to ensure uninterrupted sleep at night.
Correct Answer: A
Rationale: Regular exercise, as tolerated, improves lung function and overall health in asthma. Peak flow monitoring is typically done morning and evening. Eliminating all stressors is unrealistic. Sedatives may depress respiration and are not recommended.
The nurse is preparing a client with multiple sclerosis (MS) for discharge from the hospital to home. The nurse should tell the client:
- A. "You will need to accept the necessity for a quiet and inactive lifestyle."
- B. "Keep active, use stress reduction strategies, and avoid fatigue."
- C. "Follow good health habits to change the course of the disease."
- D. "Practice using the mechanical aids that you will need when future disabilities arise."
Correct Answer: B
Rationale: Encouraging activity, stress reduction, and fatigue management supports the client's quality of life and symptom control. Inactivity, changing disease course, or premature focus on aids are less appropriate.