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A nurse is caring for a client who has systemic lupus erythematosus. During assessment, which of the following should the nurse expect to find?
- A. Joint inflammation
- B. Butterfly' rash
- C. Esophagitis
- D. Trophil
Correct Answer: A
Rationale: The correct answer is A: Joint inflammation. Systemic lupus erythematosus (SLE) commonly presents with joint inflammation due to inflammation of the synovial membrane. This can lead to pain, swelling, and stiffness in the joints. The other choices are incorrect because: B: Butterfly rash is a characteristic facial rash seen in SLE, but it is not related to joint involvement. C: Esophagitis is inflammation of the esophagus and is not a common manifestation of SLE. D: Trophil is not a recognized term in relation to SLE or its symptoms.
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A nurse is providing discharge teaching for a client who has heart failure and is to start therapy with digoxin. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will take my digoxin if my pulse is less than 50 beats per minute.
- B. I will take this medication with fiber to prevent constipation.
- C. I will increase my dose if my vision becomes blurred.
- D. I will notify my provider if I experience muscle weakness.
Correct Answer: D
Rationale: Rationale for Correct Answer (D):
The correct answer is D because muscle weakness is a potential sign of digoxin toxicity. It is crucial for the client to notify the provider immediately to prevent serious complications. This statement indicates an understanding of the teaching regarding digoxin therapy.
Summary of Incorrect Choices:
A: Incorrect. Taking digoxin with a pulse less than 50 beats per minute can lead to bradycardia and toxicity.
B: Incorrect. Taking digoxin with fiber may decrease its absorption, reducing its effectiveness.
C: Incorrect. Blurred vision is a sign of digoxin toxicity, and the dose should be decreased, not increased.
A nurse in the emergency department is managing the care of a client who has an electrical shock injury. Which of the following actions should the nurse take first?
- A. Obtain an ECG.
- B. Administer an opioid pain medication.
- C. Infuse IV fluids to maintain urine output at 75 mL/hr.
- D. Change dressings over the entrance and exit wounds.
Correct Answer: A
Rationale: The correct answer is A: Obtain an ECG. The first step in managing a client with an electrical shock injury is to assess for any cardiac complications, as electrical shock can cause arrhythmias. Obtaining an ECG will help the nurse identify any abnormal heart rhythms and determine the need for immediate intervention. Administering opioid pain medication (B) is not a priority as assessing the cardiac status takes precedence. Infusing IV fluids (C) is important but not the first priority. Changing dressings (D) can wait until the client's immediate medical needs are addressed.
A nurse is caring for a client who has a new onset of hyperglycemic hyperosmolar state (HHS). Which of the following interventions by the nurse is the highest priority?
- A. Administer Insulin.
- B. Teach the client about manifestations of HHS.
- C. Measure the client's urinary output.
- D. Initiate IV fluid replacement.
Correct Answer: D
Rationale: The correct answer is D: Initiate IV fluid replacement. In hyperglycemic hyperosmolar state (HHS), the client is severely dehydrated due to high blood glucose levels. IV fluid replacement is the highest priority to rehydrate the client and improve circulation. Administering insulin (A) is important but not the highest priority as fluid replacement takes precedence. Teaching the client about manifestations of HHS (B) is important for long-term management but not the immediate priority. Measuring urinary output (C) is important to assess renal function but not as critical as rehydrating the client.
A nurse is providing discharge teaching to a client who is recovering from a sickle cell crisis. Which of the following instructions should the nurse include?
- A. Limit fluids to 1.5 L per day.
- B. Avoid extremely hot or cold temperatures.
- C. Avoid getting a flu vaccination.
- D. Limit alcohol intake to one drink per day.
Correct Answer: B
Rationale: The correct answer is B: Avoid extremely hot or cold temperatures. This instruction is crucial for a client recovering from a sickle cell crisis as extreme temperatures can trigger or worsen a sickle cell crisis. Hot temperatures can lead to dehydration and increase the risk of vaso-occlusive events, while cold temperatures can cause vasoconstriction, leading to further sickling of red blood cells. Limiting fluids (A) is incorrect as hydration is important to prevent complications. Avoiding a flu vaccination (C) is also incorrect as it is recommended to protect against infections that can trigger a crisis. Limiting alcohol intake (D) is not directly related to sickle cell crisis recovery.
A nurse is planning care for a client who has hemiplegia. Which of the following interventions should the nurse include?
- A. Instruct the client to sit on a rubber ring when seated in a chair.
- B. Raise the head of the client's bed to a 90° angle.
- C. Place pillows between the client's knees when in a side-lying position.
- D. Use moisturizing lotion while massaging the client's bony prominences.
Correct Answer: C
Rationale: The correct answer is C: Place pillows between the client's knees when in a side-lying position. Placing pillows between the knees helps maintain proper alignment of the hips and spine, preventing the development of pressure ulcers and improving comfort for the client. Choice A is incorrect as sitting on a rubber ring does not directly address the client's hemiplegia. Choice B is incorrect because raising the head of the bed to a 90° angle may not be suitable for a client with hemiplegia due to potential issues with positioning and pressure distribution. Choice D is incorrect as using moisturizing lotion while massaging bony prominences is not a specific intervention for hemiplegia care.