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A client with an acute exacerbation of rheumatoid arthritis (RA) has localized pain and inflammation of the fingers and feet, swelling, redness, restricted joint motion, and reports feeling fatigued. Which nursing problem has the highest priority for this client?
- A. Fatigue related to disease exacerbation.
- B. Pain related to joint inflammation
- C. Impaired physical mobility related to joint pain.
- D. Self-care deficit related to disease progression.
Correct Answer: B
Rationale: Pain is the primary symptom of RA exacerbation, impacting quality of life and requiring immediate management.
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A client admitted with thyrotoxicosis is reporting a 'pounding heart in the chest.' Which assessment finding warrants immediate intervention by the nurse?
- A. Anxiety
- B. Hyperglycemia
- C. Fever
- D. Dyspnea.
Correct Answer: D
Rationale: Dyspnea may indicate severe complications like heart failure or thyroid storm, requiring immediate intervention due to potential life-threatening respiratory distress.
The nurse establishes a nursing problem of 'Fatigue related to inability to rest comfortably secondary to rheumatoid arthritis.' Which nursing intervention should the nurse include in the plan of care for this client?
- A. Assist the client with learning how to set priorities and pace activities.
- B. Instruct the client about the importance of maintaining bedrest.
- C. Consult the discharge planner about transferring the client to an assisted living center.
- D. Offer assurance that the fatigue inducing stage of the disease does not last.
Correct Answer: A
Rationale: Pacing activities balances exertion and rest, reducing fatigue in rheumatoid arthritis, unlike bedrest, relocation, or reassurance.
The healthcare provider prescribes cefazolin 800 mg IM every six hours. The available vial is labeled, 'Cefazolin 1 gram,' and the instructions for reconstitution state, For IM use add 2.5 mL sterile water for Injection to provide a total volume of 3.0 mL. After reconstitution, the solution contains how many mg/mL? Enter numeric value only. If rounding is required, round to the nearest whole number.)
Correct Answer: 333
Rationale: One gram (1000 mg) reconstituted in 3.0 mL yields a concentration of 1000 mg / 3 mL = 333.33 mg/mL, rounded to 333 mg/mL.
Two weeks following a Billroth II (gastrojejunostomy), a client develops nausea, diarrhea, and diaphoresis after every meal. When the nurse develops a teaching plan for this client, which expected outcome statement is the most relevant?
- A. Client describes a schedule for antacid use with other prescribed medications.
- B. Client selects a pattern of small meals alternating with fluid intake.
- C. Client expresses a willingness to reduce nicotine intake.
- D. Client agrees to participate in a variety of stress reduction techniques.
Correct Answer: B
Rationale: Small, frequent meals reduce rapid gastric emptying, addressing dumping syndrome symptoms post-Billroth II.
The nurse is evaluating the effectiveness of the incentive spirometer implemented in the client's plan of care. Which outcome statement best describes the effectiveness of the incentive spirometer?
- A. Client's breath sounds are clear to auscultation bilaterally.
- B. Client exhibits a frequent productive cough.
- C. Client demonstrates proper use of an incentive spirometer.
- D. Client reports using the incentive spirometer every hour while awake.
Correct Answer: A
Rationale: Clear breath sounds indicate effective lung expansion, the primary goal of incentive spirometry, unlike cough, technique, or compliance.