Nokea
A client with rheumatoid arthritis is prescribed methotrexate. Which assessment finding requires immediate intervention?
- A. Fever of 100.4°F
- B. Positive Chvostek's sign
- C. Increased joint pain
- D. Swelling in the joints
Correct Answer: B
Rationale: A positive Chvostek's sign indicates hypocalcemia, which requires immediate intervention as it can lead to life-threatening complications. Fever, increased joint pain, and swelling in the joints are common symptoms in clients with rheumatoid arthritis but do not require immediate intervention like addressing hypocalcemia.
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The mother of an adolescent tells the clinic nurse, 'My son has athlete's foot. I have been applying triple antibiotic ointment for two days, but there has been no improvement.' What instruction should the nurse provide?
- A. Antibiotics take two weeks to become effective against fungal infections like athlete's foot.
- B. Continue using the ointment for a full week, even after the symptoms disappear.
- C. Applying too much ointment can reduce its effectiveness. Apply a thin layer to prevent maceration.
- D. Stop using the ointment and encourage complete drying of the feet and wearing clean socks.
Correct Answer: D
Rationale: The correct answer is D. Athlete's foot (tinea pedis) is a fungal infection, not a bacterial infection that would respond to antibiotics. The primary management involves keeping the feet well-ventilated, dry after bathing, and wearing clean socks to prevent moisture buildup, which promotes fungal growth. Using an antibiotic ointment like triple antibiotic ointment is not effective for treating athlete's foot. Therefore, the nurse should advise the mother to stop using the antibiotic ointment and focus on promoting proper foot hygiene to manage the fungal infection. Choices A, B, and C are incorrect as they do not address the fungal nature of athlete's foot and the ineffectiveness of antibiotic ointments in its treatment.
The nurse is caring for a client with a history of myocardial infarction who is experiencing chest pain. Which diagnostic test should the nurse anticipate preparing the client for first?
- A. Electrocardiogram (ECG)
- B. Chest X-ray
- C. Arterial blood gases (ABGs)
- D. Echocardiogram
Correct Answer: A
Rationale: Corrected Rationale: An electrocardiogram (ECG) should be performed first to assess for cardiac ischemia in a client with a history of myocardial infarction and chest pain. An ECG provides immediate information about the heart's electrical activity, helping to identify changes indicative of cardiac ischemia or infarction. Chest X-ray (Choice B) is not the initial diagnostic test for assessing chest pain related to myocardial infarction. Arterial blood gases (Choice C) are used to assess oxygenation and acid-base balance but are not the primary diagnostic test for myocardial infarction. An echocardiogram (Choice D) may provide valuable information about cardiac structure and function, but it is not the first-line diagnostic test for acute chest pain in a client with a history of myocardial infarction.
A male client with hypertension, who received new antihypertensive prescriptions at his last visit, returns to the clinic two weeks later to evaluate his blood pressure (BP). His BP is 158/106, and he admits that he has not been taking the prescribed medication because the drugs make him 'feel bad'. In explaining the need for hypertension control, the nurse should stress that an elevated BP places the client at risk for which pathophysiological condition?
- A. Blindness due to cataracts
- B. Acute kidney injury due to glomerular damage
- C. Stroke secondary to hemorrhage
- D. Heart block due to myocardial damage
Correct Answer: C
Rationale: The correct answer is C, 'Stroke secondary to hemorrhage.' Uncontrolled hypertension can lead to the weakening of blood vessels in the brain, increasing the risk of a stroke due to hemorrhage. This can result in serious neurological deficits or even death. Choices A, B, and D are incorrect because while hypertension can have various complications including vision changes, kidney damage, and heart problems, the most immediate and severe risk associated with uncontrolled hypertension is a stroke from cerebral hemorrhage.
The nurse notes that a client has been receiving hydromorphone (Dilaudid) every six hours for four days. What assessment is most important for the nurse to complete?
- A. Auscultate the client's bowel sounds
- B. Observe for edema around the ankles
- C. Measure the client's capillary glucose level
- D. Count the apical and radial pulses simultaneously
Correct Answer: A
Rationale: The correct answer is to auscultate the client's bowel sounds. Hydromorphone is a potent opioid analgesic that can slow peristalsis and commonly cause constipation. By assessing the client's bowel sounds, the nurse can monitor for any signs of decreased bowel motility or potential constipation. Observing for edema (Choice B) is not directly related to hydromorphone administration. Measuring capillary glucose levels (Choice C) is not the priority in this situation. Counting the apical and radial pulses simultaneously (Choice D) is not specifically indicated in this scenario involving hydromorphone administration.
The unit clerk reports to the charge nurse that a healthcare provider has written several prescriptions that are illegible and it appears the healthcare provider used several unapproved abbreviations in the prescriptions. What actions should the charge nurse take?
- A. Call the healthcare provider who wrote the prescription
- B. Attempt to clarify the prescriptions with the pharmacist
- C. Administer the medications as prescribed
- D. Ask another healthcare provider for clarification
Correct Answer: A
Rationale: The correct action for the charge nurse to take is to call the healthcare provider who wrote the illegible prescriptions. It is crucial to clarify illegible prescriptions directly with the provider to ensure patient safety and prevent medication errors. Option B, attempting to clarify with the pharmacist, may lead to misinterpretation and is not the recommended first step. Administering the medications as prescribed without clarity can jeopardize patient safety, making option C incorrect. Asking another healthcare provider for clarification (option D) may not be effective as the responsibility lies with the provider who wrote the prescription.