Nokea
A nurse is caring for a client with a musculoskeletal disorder who is experiencing a significant impairment in the ability to ambulate due to pain. As a result, the client spends a majority of time in bed. Which of the following would the nurse most likely include in the client's plan of care?
- A. Changing the client's position every 2 hours
- B. Changing the bed linens every hour
- C. Encouraging the client to walk with assistance
- D. Encouraging the client to exercise with assistance
Correct Answer: A
Rationale: The nurse should change the client's position every 2 hours and inspect pressure sites for skin breakdown. The nurse need not change linens every hour. Once the client's condition improves, then encouraging ambulation with assistance and exercises would be appropriate.
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A nurse monitors a client closely for methotrexate toxicity when the client is also prescribed which of the following? Select all that apply.
- A. Aspirin (Ecotrin)
- B. Cephalexin (Keflex)
- C. Sulfamethoxazole/trimethoprim (Septra)
- D. Ibuprofen (Motrin)
- E. Diclofenac (Voltaren)
Correct Answer: A,C,D,E
Rationale: The nurse should closely monitor the client for methotrexate toxicity when methotrexate is given with aspirin (Ecotrin), sulfa antibiotics (Septra), and NSAIDs (ibuprofen and diclofenac).
A nurse would monitor a client closely for increased CNS depressant effects when a skeletal muscle relaxant is used concomitantly with which of the following? Select all that apply.
- A. Antihistamine
- B. Oral contraceptives
- C. Alcohol
- D. Opiates
- E. Antidiabetic medications
Correct Answer: A,C,D
Rationale: The concomitant use of skeletal muscle relaxants and antihistamines, alcohol, opiates, or sedatives can result in increased CNS depressant effects.
A client with gout has not responded to the usual medications. The primary health care provider prescribes a pegloticase infusion. Based on the nurse's understanding of this drug, which nursing diagnosis would be most appropriate?
- A. Risk for Injury
- B. Acute Pain
- C. Impaired Comfort: Gastric Distress
- D. Risk for Allergic Response
Correct Answer: D
Rationale: When first-line treatments for gout are not successful, sometimes drugs that are more toxic may be prescribed, such as the pegloticase infusion. During the infusion the patient is closely monitored for the development of adverse reactions, in particular anaphylaxis. Should an anaphylactic reaction occur, the infusion center staff members are prepared to start resuscitative measures as emergency personnel are notified.
A nurse is caring for a client who is receiving cyclobenzaprine. The nurse would expect to assess which of the following as indicating the therapeutic effect of the drug?
- A. Reduction of muscle spasm
- B. Prevention of convulsion
- C. Relief from anxiety
- D. Relief from nervous disorder
Correct Answer: A
Rationale: Cyclobenzaprine affects muscle tone, thereby causing reduction of muscle spasm. Administration of cyclobenzaprine does not result in prevention of convulsion, relief from anxiety, or relief from nervous disorder.
Before administering dantrolene to a client, the nurse checks the client's medical history for possible contraindications for use. Which condition would the nurse identify as problematic? Select all that apply.
- A. Hypertension
- B. Atrial fibrillation
- C. Hepatic disease
- D. Diabetes
- E. Lactation
Correct Answer: C,E
Rationale: The use of dantrolene is contraindicated during lactation and in clients with active hepatic disease and muscle spasm caused by rheumatic disorders.