Nokea
A male client with rheumatoid arthritis is scheduled for a procedure in the morning. The procedure cannot be completed because of early morning stiffness. Which intervention should the nurse implement?
- A. Assign a UAP to assist the client with a warm shower early in the morning.
- B. Provide the client with a warm blanket to reduce stiffness.
- C. Delay the procedure until the client is less stiff.
- D. Encourage the client to perform range-of-motion exercises.
Correct Answer: A
Rationale: A warm shower can help reduce morning stiffness, making the procedure more comfortable for the client. This intervention promotes comfort and mobility, addressing the immediate issue of stiffness. Providing a warm blanket (choice B) may offer some comfort but will not address the stiffness as effectively as a warm shower. Delaying the procedure (choice C) may inconvenience the client and not address the underlying stiffness issue. Encouraging range-of-motion exercises (choice D) is important for long-term management but may not provide immediate relief from the stiffness that is hindering the procedure.
You may also like to solve these questions
A 65-year-old male client with a history of smoking and high cholesterol is admitted with shortness of breath and 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. Pulmonary function tests (PFTs)
Correct Answer: A
Rationale: The correct answer is an Electrocardiogram (ECG). An ECG should be performed first to assess for cardiac ischemia, especially given the client's symptoms and history. Chest X-ray (Choice B) may be ordered to evaluate the lungs but would not be the initial test for this client presenting with chest pain and shortness of breath. Arterial blood gases (ABGs) (Choice C) are used to assess oxygenation and acid-base balance but are not the primary diagnostic test for a client with suspected cardiac issues. Pulmonary function tests (PFTs) (Choice D) are used to assess lung function and would not be the first test indicated in this scenario.
A client with chronic kidney disease (CKD) is scheduled for a renal biopsy. Which laboratory value is most concerning?
- A. Serum potassium of 5.5 mEq/L
- B. Serum creatinine of 1.5 mg/dl
- C. Serum creatinine of 2.5 mg/dl
- D. White blood cell count of 8,000/mm3
Correct Answer: C
Rationale: A serum creatinine level of 2.5 mg/dl is the most concerning laboratory value in a client with chronic kidney disease scheduled for a renal biopsy. An elevated serum creatinine level indicates impaired kidney function, which is critical information before performing a renal biopsy. Option A (Serum potassium of 5.5 mEq/L) may be concerning for hyperkalemia but is not directly related to the renal biopsy procedure. Option B (Serum creatinine of 1.5 mg/dl) is within normal limits, suggesting relatively normal kidney function. Option D (White blood cell count of 8,000/mm3) is within the normal range and not directly related to the renal biopsy procedure or CKD management.
The nurse is assisting the mother of a child with phenylketonuria (PKU) to select foods that are in keeping with the child's dietary restrictions. Which foods are contraindicated for this child?
- A. Wheat products
- B. Foods sweetened with aspartame
- C. High-fat foods
- D. High-calorie foods
Correct Answer: B
Rationale: The correct answer is B: Foods sweetened with aspartame. Aspartame should not be consumed by a child with PKU because it is converted to phenylalanine in the body, which can be harmful to individuals with PKU. Choice A (Wheat products) is not specifically contraindicated for PKU. Choice C (High-fat foods) and Choice D (High-calorie foods) are not typically restricted in PKU diets unless they contain high levels of phenylalanine.
A client who is post-op day 1 after abdominal surgery reports pain at the incision site. The nurse notes the presence of a small amount of serosanguineous drainage. What is the most appropriate nursing action?
- A. Apply a sterile dressing to the incision.
- B. Reinforce the dressing and document the findings.
- C. Remove the dressing and assess the incision site.
- D. Notify the healthcare provider.
Correct Answer: B
Rationale: The correct answer is to reinforce the dressing and document the findings. It is important to monitor the incision site closely after surgery, especially when there is a small amount of serosanguineous drainage. Reinforcing the dressing helps maintain cleanliness and pressure on the wound. Documenting the findings is crucial for tracking the client's progress and alerting healthcare providers if necessary. Applying a sterile dressing (Choice A) may not be needed if the current dressing is intact. Removing the dressing (Choice C) can increase the risk of contamination. Notifying the healthcare provider (Choice D) is not the first step for minor drainage on post-op day 1.
A client with type 2 diabetes is admitted with hyperglycemic hyperosmolar syndrome (HHS). Which intervention should the nurse implement first?
- A. Administer intravenous fluids.
- B. Monitor the client's urine output.
- C. Obtain a blood glucose level.
- D. Administer 50% dextrose IV push.
Correct Answer: D
Rationale: The correct answer is to administer 50% dextrose IV push first. In hyperglycemic hyperosmolar syndrome, the main goal is to rapidly reduce blood glucose levels to prevent further complications. Administering dextrose intravenously can help reverse the effects of high blood glucose levels quickly. Administering intravenous fluids, monitoring urine output, and obtaining a blood glucose level are important interventions but are not the first priority in treating HHS. Administering 50% dextrose IV push takes precedence as it directly addresses the elevated blood glucose levels.