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A client is in the acute phase of rheumatoid arthritis. Which of the following should the nurse identify as lowest priority in the plan of care?
- A. Relieving pain.
- B. Preserving joint function.
- C. Maintaining usual ways of accomplishing tasks.
- D. Preventing joint deformity.
Correct Answer: C
Rationale: During the acute phase, relieving pain, preserving joint function, and preventing deformity are critical to manage inflammation and prevent long-term damage. Maintaining usual ways of accomplishing tasks is less urgent.
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The nurse notices a pair of nervous-acting individuals entering the emergency department. When reporting suspicious activity, the nurse should include which of the following in the report? Select all that apply.
- A. Vehicle/s description.
- B. Current location of parties involved.
- C. Names and phone numbers of parties involved.
- D. Relationship to hospitalized client.
- E. Tone of voice of each party involved.
Correct Answer: A,B
Rationale: Reporting suspicious activity should include objective details like vehicle description and current location to aid security response. Names, relationships, and tone are less critical unless directly relevant.
A client with rheumatoid arthritis is experiencing fatigue. Which nursing intervention is most appropriate?
- A. Encourage high-intensity exercise.
- B. Plan rest periods throughout the day.
- C. Increase carbohydrate intake.
- D. Limit fluid intake to reduce swelling.
Correct Answer: B
Rationale: Planning rest periods conserves energy and reduces fatigue in rheumatoid arthritis.
The nurse finds the apical impulse below the fifth intercostal space. The nurse suspects:
- A. Left atrial enlargement.
- B. Left ventricular enlargement.
- C. Right atrial enlargement.
- D. Right ventricular enlargement.
Correct Answer: B
Rationale: An apical impulse below the fifth intercostal space suggests left ventricular enlargement, common in heart failure due to ventricular dilation.
The nurse is preparing to insert a peripheral vascular access device. Place the following actions in the order in which they need to be performed, starting from first to last.
- A. Apply sterile dressing over the intravenous site.
- B. Clean the selected area using an alcohol-based 2% chlorhexidine solution using friction for 30 seconds.
- C. Place the tourniquet 10 to 15 cm (4-6 inches) above the proposed site.
- D. Insert the intravenous catheter at a 15 to 30 degree angle.
- E. Advance the catheter until a flash of blood is seen, then advance the catheter into the vein while removing the needle.
- F. Palpate vein at intended insertion site by pressing downward.
- G. Release tourniquet temporarily.
Correct Answer: C,F,G,B,D,E
Rationale: The correct order ensures proper vein selection, site preparation, catheter insertion, and securement while minimizing complications.
The nurse is developing a plan of care for a client with Crohn's disease who is receiving total parenteral nutrition (TPN). Which of the following interventions should the nurse include? Select all that apply.
- A. Monitoring vital signs once a shift.
- B. Weighing the client daily.
- C. Changing the central venous line dressing daily.
- D. Monitoring the I.V. infusion rate hourly.
- E. Taping all I.V. tubing connections securely.
Correct Answer: B,C,D,E
Rationale: For a client on TPN, daily weight monitoring (B), daily dressing changes (C), hourly infusion rate checks (D), and securing tubing connections (E) are critical to prevent complications like infection or fluid imbalance. Vital signs once a shift (A) is insufficient; more frequent monitoring is needed. CN: Pharmacological and parenteral therapies; CL: Create