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A nurse in a provider’s office is assessing a client who has rheumatoid arthritis (RA). Which of the following findings is a late manifestation?
- A. Low-grade fever
- B. Weight loss
- C. Anorexia
- D. Knuckle deformity
Correct Answer: D
Rationale: The correct answer is D: Knuckle deformity. Knuckle deformity in rheumatoid arthritis is a late manifestation due to prolonged inflammation and joint damage. This occurs after the initial symptoms such as low-grade fever, weight loss, and anorexia. Low-grade fever, weight loss, and anorexia are early systemic manifestations of RA caused by inflammation and metabolic changes. Knuckle deformity indicates advanced joint damage and chronic inflammation. Therefore, it is considered a late manifestation compared to the other options.
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A nurse is reviewing the laboratory results of a client who has a pressure ulcer. The nurse should identify an elevation in which of the following laboratory values as an indication that the client has developed an infection?
- A. WBC count
- B. BUN
- C. Potassium
Correct Answer: A
Rationale: The correct answer is A: WBC count. An elevation in WBC count indicates the presence of infection as the body releases more white blood cells to fight off pathogens. In the case of a pressure ulcer, an increased WBC count suggests bacterial invasion and inflammation at the site of the ulcer. BUN (choice B) and Potassium (choice C) are not specific indicators of infection and are more related to kidney function and electrolyte balance, respectively. Therefore, they are not appropriate for determining infection in this context.
A nurse is caring for a toddler who is 24 hours postoperative following a cleft palate repair. Which of the following actions should the nurse take?
- A. Apply bilateral wrist restraints.
- B. Administer opioids for pain.
- C. Implement a soft diet.
- D. Offer fluids through a straw.
Correct Answer: C
Rationale: Correct Answer: C. Implement a soft diet.
Rationale: A soft diet is appropriate post-cleft palate repair to minimize trauma to the surgical site and promote healing. It helps prevent injury and discomfort to the surgical area, allowing for adequate nutrition without causing harm.
Incorrect Choices:
A: Applying bilateral wrist restraints is unnecessary and could potentially harm the toddler, leading to increased agitation and discomfort.
B: Administering opioids for pain may not be necessary for a toddler post-cleft palate repair unless there are specific indications for severe pain.
D: Offering fluids through a straw can increase the risk of aspiration and compromise the surgical site's healing process. It is not recommended post-cleft palate repair.
A nurse is providing teaching to a client with a colostomy about appropriate food choices. Which of the following foods should the nurse include in the teaching?
- A. Dried fruits
- B. Dried peas
- C. Eggs
- D. Pasta
Correct Answer: C
Rationale: The correct answer is C: Eggs. Eggs are a good source of protein, which is important for clients with a colostomy to promote healing and overall health. They are easily digestible and less likely to cause issues like blockages or gas. Dried fruits (choice A) and dried peas (choice B) can be high in fiber and may lead to digestive problems for colostomy clients. Pasta (choice D) can also be difficult to digest and may cause discomfort. Eggs are a versatile and nutritious option that can be beneficial for clients with a colostomy.
A nurse is caring for a client who develops an airway obstruction from a foreign body but remains conscious. Which of the following actions should the nurse take first?
- A. Perform a blind finger sweep.
- B. Turn the client to the side.
- C. Insert an oral airway.
- D. Administer the abdominal thrust maneuver.
Correct Answer: D
Rationale: The correct answer is D: Administer the abdominal thrust maneuver. This action should be taken first because it is the appropriate intervention for a conscious individual with an airway obstruction. The abdominal thrust maneuver helps dislodge the foreign body by creating pressure to expel it. Performing a blind finger sweep (A) can push the object further down the airway. Turning the client to the side (B) may not effectively clear the airway obstruction. Inserting an oral airway (C) could worsen the obstruction if not inserted correctly. Therefore, administering the abdominal thrust maneuver is the priority to clear the airway obstruction in a conscious individual.
A nurse is preparing to administer 40 mg of furosemide IV. Available is furosemide 10 mg/mL. How many mL should the nurse administer per dose?
Correct Answer: 4
Rationale: Correct Answer: A nurse should administer 4 mL of furosemide per dose. To calculate this, divide the total dose (40 mg) by the concentration (10 mg/mL). 40 mg ÷ 10 mg/mL = 4 mL. This ensures the correct dosage is administered.
Choice B: Incorrect. This choice does not follow the correct calculation method and does not provide the accurate dosage.
Choice C: Incorrect. This choice does not consider the concentration of the medication and does not provide the correct amount to administer.
Choice D: Incorrect. This choice does not involve the necessary division of the total dose by the concentration, resulting in an incorrect answer.
Choice E: Incorrect. This choice does not show a clear calculation method or consideration of the medication concentration.
Choice F: Incorrect. This choice lacks any calculation or explanation, making it an insufficient answer.
Choice G: Incorrect. This choice does not provide any reasoning or calculation to support the amount to administer, making it an inadequate