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A client with rheumatoid arthritis is about to begin aspirin therapy to reduce inflammation. When teaching the client about aspirin, the nurse discusses adverse reactions to prolonged aspirin therapy. These include:
- A. Weight gain
- B. Respiratory acidosis
- C. Fine motor tremors
- D. Bilateral hearing loss
Correct Answer: B
Rationale: The correct answer is B: Respiratory acidosis. Aspirin can lead to respiratory acidosis due to its effect on the respiratory center in the brainstem. It causes hyperventilation, leading to respiratory alkalosis initially, followed by respiratory acidosis as compensation mechanism fails. Weight gain is not a typical adverse reaction of aspirin. Fine motor tremors are not associated with aspirin therapy. Bilateral hearing loss is a rare but serious side effect of aspirin overdose, not prolonged therapy.
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The client with rheumatoid arthritis reports GI irritation after taking piroxicam (Feldene). To prevent GI upset, the nurse should provide which instruction?
- A. Space the administration every 4
- B. Use the drug for a short time only
- C. Decrease the piroxicam dosage
- D. Take piroxicam with food or oral antacid
Correct Answer: D
Rationale: The correct answer is D. Taking piroxicam with food or an oral antacid can help reduce GI irritation as it can protect the stomach lining. Piroxicam is known to cause GI upset due to its effects on prostaglandin synthesis. Spacing the administration every 4 hours (choice A) may not necessarily prevent GI upset. Using the drug for a short time only (choice B) may not address the immediate concern of GI irritation. Decreasing the piroxicam dosage (choice C) may not be necessary if taking it with food or an antacid can effectively alleviate the GI upset.
The nurse assesses the motor functions during a neurologic examination of a client. Which of the ff steps will help the nurse perform the examination effectively? Choose all that apply
- A. Allow the client to grasp the nurses hand firmly
- B. Check the patient’s sensitivity to heat, cold, touch, and pain.
- C. Ask the client to pick up small and large objects between the thumb and forefinger
- D. Ask questions that require cognition and logic
Correct Answer: A
Rationale: Step-by-step rationale:
1. Allowing the client to grasp the nurse's hand firmly assesses grip strength and motor coordination.
2. This step helps evaluate the client's ability to follow instructions and perform a coordinated motor task accurately.
3. Assessing grip strength is essential in determining any muscle weakness or neurological deficits.
4. It also provides insight into the client's motor function and coordination abilities.
Summary:
- Choice B is incorrect because it focuses on sensory functions rather than motor functions.
- Choice C assesses fine motor skills, not grip strength and coordination.
- Choice D evaluates cognition and logic, which are not directly related to motor function assessment.
Which of the ff nursing interventions is taken as a precautionary measure if shock develops when a client with a spinal cord injury is hospitalized?
- A. An IV line is inserted to provide access to a vein
- B. The head and back are immobilized mechanically with a cervical collar and back support
- C. Traction with weights and pulleys is applied
- D. A turning frame is used EMERGENCY AND DISASTER NURSING SITUATION: A group of high school teenagers went camping to Sohoton this summer for one week. You are the nurse assigned to this camp. For the first three days, you were busy with several emergencies.
Correct Answer: A
Rationale: The correct answer is A: An IV line is inserted to provide access to a vein. In shock, adequate intravenous access is crucial to administer fluids and medications rapidly. This helps stabilize the client's condition by restoring blood volume and improving circulation. Choice B is incorrect as immobilization is not a primary intervention for shock in this scenario. Choice C, traction, is not appropriate for managing shock but rather for stabilizing spinal cord injuries. Choice D, using a turning frame, is not relevant to managing shock and does not address the immediate need for fluid resuscitation.
Which scenario best illustrates the nurse using data validation when making a nursing clinical decision for a patient? The nurse determines to remove a wound dressing when the patient reveals the time
- A. of the last dressing change and notices old and new drainage. The nurse administers pain medicine due at 1700 at 1600 because the patient reports
- B. increased pain and the family wants something done. The nurse immediately asks the health care provider for an order of potassium when a
- C. patient reports leg cramps.
- D. The nurse elevates a leg cast when the patient reports decreased mobility.
Correct Answer: A
Rationale: The correct answer is A because it demonstrates data validation in making a nursing clinical decision. The nurse assesses the time of the last dressing change and compares it with the appearance of old and new drainage. This process ensures that the decision to remove the wound dressing is based on accurate and validated data, leading to appropriate patient care.
Choice B is incorrect because it does not involve data validation. The decision is driven by increased pain and family requests, without verifying the underlying cause.
Choice C is incorrect as it involves responding to a patient's reported symptom (leg cramps), but it does not involve data validation in making the clinical decision.
Choice D is incorrect as it relies solely on the patient's report of decreased mobility without further data validation.
Which nursing intervention is appropriate for the nurse to take when setting up supplies for a client who requires a blood transfusion?
- A. Add any needed IV medication in the blood bag within one hour of planned infusion
- B. Obtain blood bag from laboratory and leave at room temperature for at least one hour prior to infusion
- C. Prime tubing of blood administration set with 0.9% NS solution, completely, filling filter
- D. Inadequate dietary intake
Correct Answer: C
Rationale: The correct answer is C because priming the tubing of the blood administration set with 0.9% NS solution ensures that there are no air bubbles in the tubing, preventing air embolism when the blood transfusion starts. This step also ensures that the blood flows smoothly and prevents clotting in the tubing.
Choice A is incorrect because adding IV medication in the blood bag can lead to incompatibility issues and should not be done without proper verification and approval.
Choice B is incorrect because leaving the blood bag at room temperature for an hour can lead to bacterial growth in the blood, increasing the risk of infection when transfused.
Choice D is unrelated to setting up supplies for a blood transfusion and does not address the immediate nursing intervention required in this situation.