Nokea
A client has newly diagnosed systemic lupus erythematosus (SLE). What instruction by the nurse is most important?
- A. Be sure you get enough sleep at night
- B. Eat plenty of high-protein, high-iron foods
- C. Notify your provider at once if you get a fever
- D. Weigh yourself every day on your home scale
Correct Answer: C
Rationale: A fever is a classic sign of a lupus flare and should be reported immediately. Rest and nutrition are important but do not take priority over teaching the client what to do if they develop an elevated temperature.
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A client with rheumatoid arthritis (RA) is on the postoperative nursing unit after having elective surgery. The client reports that the arm feels like pins and needles and that the neck is painful since returning from surgery. What action by the nurse is best?
- A. Assist the client to change positions
- B. Encourage range of motion of the neck
- C. Notify the provider immediately
- D. Provide pain medication as ordered
Correct Answer: C
Rationale: Clients with RA can have cervical joint involvement. This can lead to an emergent situation due to potential spinal cord compression. The nurse should notify the provider immediately to assess for this serious complication.
A client is scheduled to have a hip replacement. Preoperatively, the client is found to be mildly anemic and the surgeon states the client may need a blood transfusion during or after the surgery. What action by the preoperative nurse is most important?
- A. Administer preoperative medications as prescribed
- B. Ensure that a consent for transfusion is on the chart
- C. Teach the client about foods high in protein and iron
- D. Monitor the client's hemoglobin levels
Correct Answer: B
Rationale: The preoperative nurse should ensure that all valid consents are on the chart, including one for blood transfusions if this may be needed. This is critical for legal and ethical reasons.
A client comes to the family medicine clinic and reports joint pain and stiffness. The nurse is asked to assess the client for Heberden's nodules. What assessment technique is correct?
- A. Inspect the client's distal finger joints
- B. Palpate the client's upper body lymph nodes
- C. Assess the client's range of motion
- D. Perform a musculoskeletal strength test
Correct Answer: A
Rationale: Heberden's nodules are bony swellings at the distal interphalangeal joints, commonly associated with osteoarthritis. Inspecting the distal finger joints is the correct assessment technique.
A client who has had systemic lupus erythematosus (SLE) for many years is in the clinic reporting hip pain with ambulation. Which action by the nurse is best?
- A. Assess if the client has been taking steroids
- B. Facilitate a consultation with physical therapy
- C. Measure the range of motion in both hips
- D. Notify the health care provider immediately
Correct Answer: A
Rationale: Steroid use is common in clients with SLE and can lead to osteonecrosis (bone necrosis). The nurse should determine if the client has been taking a steroid. Physical therapy may be beneficial, but there is not enough information about the client yet. Measuring range of motion is best done by the physical therapist. Notifying the provider immediately is not warranted.
A nurse is teaching a client with rheumatoid arthritis (RA) who is prescribed etanercept (Enbrel). What information is most important for the nurse to teach this client?
- A. Administer the medication via subcutaneous injection twice a week
- B. Use heat on the injection site to reduce pain
- C. Avoid large crowds or people who are ill
- D. Monitor for signs of infection daily
Correct Answer: A
Rationale: Etanercept is given as a subcutaneous injection twice a week. The nurse should teach the client how to self-administer the medication. The other options are not appropriate for etanercept.