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A nurse is assessing a client who has chronic venous insufficiency. Which of the following findings should the nurse expect?
- A. Dependent rubor
- B. Thick, deformed toenails
- C. Hair loss
- D. Edema
Correct Answer: D
Rationale: The correct answer is D: Edema. In chronic venous insufficiency, impaired blood flow leads to fluid accumulation in the affected limb, causing swelling or edema. This occurs due to increased venous pressure and decreased venous return. Dependent rubor (choice A) is seen in arterial insufficiency, not venous. Thick, deformed toenails (choice B) and hair loss (choice C) are not typically associated with chronic venous insufficiency. Edema is a hallmark sign due to venous stasis and capillary leakage.
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A nurse is providing discharge instructions to a client who has rheumatoid arthritis and a prescription for oral betamethasone. Which of the following statements should the nurse make about how to take this medication?
- A. Take the medication with orange juice.
- B. Take the medication between meals.
- C. Take the medication on an empty stomach.
- D. Take the medication with milk.
Correct Answer: D
Rationale: The correct answer is D: Take the medication with milk. Betamethasone can cause stomach irritation, so taking it with milk can help reduce this side effect. Milk coats the stomach lining, providing a protective barrier. This helps to minimize the risk of gastrointestinal upset.
A: Taking the medication with orange juice is not recommended as it can increase stomach irritation due to its acidity.
B: Taking the medication between meals may not provide the same protective effect on the stomach lining as taking it with milk.
C: Taking the medication on an empty stomach can increase the risk of gastrointestinal irritation and should be avoided.
E, F, G: These options are not relevant to the administration of betamethasone.
A nurse is preparing to administer dextrose 5% in 0.45% sodium chloride IV to infuse at 100 mL/hr. The nurse is using microtubing. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round to the nearest whole number)
Correct Answer: 100
Rationale: The correct answer is 100 gtt/min. To calculate the IV flow rate in gtt/min for microtubing, you can use the formula: gtt/min = (mL/hr x tubing factor) / 60. In this case, the mL/hr is 100, and for microtubing, the tubing factor is usually 60. So, (100 x 60) / 60 = 100 gtt/min. This ensures the dextrose 5% in 0.45% sodium chloride solution is infused at the correct rate. Other choices would be incorrect because they do not follow the correct calculation for microtubing flow rates.
A nurse enters a client’s room and finds him on the floor in the clonic phase of a tonic-clonic seizure. Which of the following actions should the nurse take?
- A. Place a pillow under the client’s head.
- B. Insert a padded tongue blade into the client’s mouth.
- C. Apply a face mask for oxygen administration.
- D. Gently restrain the client’s extremities.
Correct Answer: A
Rationale: The correct action is to place a pillow under the client's head. This helps to protect the client's head from injury during the seizure. It is important to maintain a patent airway and prevent head injury. Inserting a padded tongue blade (choice B) could cause injury or obstruct the airway. Applying a face mask for oxygen (choice C) may not be necessary at this point and can be done after the seizure stops. Gently restraining the client's extremities (choice D) can cause further injury. It is crucial to prioritize safety and comfort during a seizure.
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.
A nurse is assessing a client who is receiving vancomycin. The nurse notes a flushing of the neck and tachycardia. Which of the following actions should the nurse take?
- A. Decrease the infusion rate on the IV.
- B. Document that the client experienced an anaphylactic reaction to the medication.
- C. Change the IV infusion site.
- D. Apply cold compresses to the neck area.
Correct Answer: A
Rationale: The correct answer is A: Decrease the infusion rate on the IV. Flushing of the neck and tachycardia are common signs of "Red Man Syndrome," a potential adverse reaction to vancomycin infusion. Decreasing the infusion rate can help alleviate these symptoms. Documentation (B) of an anaphylactic reaction is inaccurate because these symptoms are not indicative of an anaphylactic reaction. Changing the IV site (C) is unnecessary as the symptoms are likely due to the medication itself. Applying cold compresses (D) is not effective for this reaction.