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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.
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A home health care nurse is visiting a client discharged home after a hip replacement. The client is still using a walker. What safety precautions can the nurse recommend to the client? (Select all that apply.)
- A. Buy and install an elevated toilet seat
- B. Install grab bars in the shower and by the toilet
- C. Step into the bathtub with the affected leg first
- D. Remove throw rugs throughout the house
- E. Use a shower chair
Correct Answer: A,B,D,E
Rationale: Buying and installing an elevated toilet seat, installing grab bars, removing throw rugs, and using a shower chair will all promote safety for this client. The client is still on partial weight-bearing, so stepping into the bathtub with the affected leg first is not appropriate.
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 client is getting out of bed into the chair for the first time after an uncemented hip replacement. What action by the nurse is most important?
- A. Have adequate help to transfer the client
- B. Provide brown socks to transfer the client
- C. Tell the client full weight bearing is allowed
- D. Use a footstool to elevate the client's leg
Correct Answer: A
Rationale: The client with an uncemented hip will be on toe-touch only right after surgery. The nurse should ensure adequate help to transfer the client while preventing falls. Slippery socks and elevating the leg are not appropriate.
A nurse is caring for a client after joint replacement surgery. What action by the nurse is most important to prevent wound infection?
- A. Assess the client's white blood cell count
- B. Inspect the client's white blood cell count
- C. Monitor the client's temperature every 4 hours
- D. Use aseptic technique for dressing changes
Correct Answer: D
Rationale: Preventing surgical wound infection is a primary responsibility of the nurse, who must use aseptic technique to prevent wound infection. Other actions do not prevent infection but can lead to early detection of an infection that is already present.
A nurse is teaching a female client with rheumatoid arthritis (RA) about taking methotrexate (MTX) for disease control. What information does the nurse include? (Select all that apply.)
- A. Avoid acetaminophen or over-the-counter medication
- B. It may take several weeks to become effective
- C. Pregnancy and breast-feeding are not affected by MTX
- D. You may find that folic acid, a B vitamin, reduces side effects
- E. Avoid crowds and sick people
Correct Answer: A,B,D,E
Rationale: MTX is a disease-modifying antirheumatic drug and is used as a first-line drug for RA. MTX can cause liver toxicity, so the client should be advised to avoid medications that contain acetaminophen. It may take weeks to effectively treat RA. MTX can cause immunosuppression, so avoiding sick people and crowds is important. Folic acid helps reduce side effects for some people. Pregnancy and breast-feeding are contraindicated while on this drug.