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A nurse is completing a physical assessment of a client who has early osteoarthritis. Which of the following manifestations should the nurse expect?
- A. Ulnar deviation
- B. Symmetric joints affected
- C. Pain worsens with activity
- D. Weight loss
Correct Answer: C
Rationale: The correct answer is C: Pain worsens with activity. In osteoarthritis, pain typically worsens with movement or activity due to the degeneration of joint cartilage causing friction between bones. This is a hallmark symptom of osteoarthritis. Ulnar deviation (A) is more commonly seen in rheumatoid arthritis. Symmetric joints affected (B) is also more characteristic of rheumatoid arthritis rather than osteoarthritis. Weight loss (D) is not a typical manifestation of osteoarthritis, unless it is due to decreased physical activity from pain.
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A nurse is preparing to administer a bisacodyl suppository to a client. Which of the following actions should the nurse take? (Select all that apply)
- A. Don sterile gloves.
- B. Position the client supine with knees bent.
- C. Use a rectal applicator for insertion.
- D. Insert the suppository just beyond the internal sphincter.
- E. Lubricate the index finger.
Correct Answer: D,E
Rationale: The correct actions for administering a bisacodyl suppository are to insert it just beyond the internal sphincter (D) to ensure proper absorption and effectiveness. Lubricating the index finger (E) helps facilitate easier insertion and reduces discomfort for the client. Donning sterile gloves (A) is not necessary for this procedure. Positioning the client supine with knees bent (B) is not required; the Sims position is typically used. Using a rectal applicator for insertion (C) is not recommended for bisacodyl suppositories.
A nurse is caring for a client who asks how albuterol helps his breathing. Which of the following responses should the nurse make? (Select all that apply)
- A. The medication will reduce inflammation.
- B. The medication will decrease coughing episodes.
- C. The medication will prevent wheezing.
- D. The medication will open the airway.
- E. The medication will stimulate the flow of mucus.
Correct Answer: C,D
Rationale: Correct Answer: C,D
Rationale:
C: The medication will prevent wheezing. Albuterol is a bronchodilator that works by relaxing the muscles in the airways, preventing and relieving wheezing.
D: The medication will open the airway. Albuterol acts by opening the airways, making it easier for the client to breathe.
Summary:
A: The medication will reduce inflammation. Albuterol does not directly reduce inflammation; it primarily works as a bronchodilator.
B: The medication will decrease coughing episodes. While albuterol may indirectly reduce coughing by improving breathing, its primary action is not to decrease coughing.
E: The medication will stimulate the flow of mucus. Albuterol does not stimulate mucus flow; it primarily works to open the airways and relieve bronchospasm.
A nurse is preparing to administer 1 mg vitamin K to a newborn. The medication is available in 1 mg/0.5 mL. How much should the nurse administer? (Round to the nearest tenth. Use a leading zero when applicable. Do not use a trailing zero.)
Correct Answer: 0.5
Rationale: Correct Answer: 0.5 mL
Rationale: To administer 1 mg of vitamin K, the nurse should administer 0.5 mL, as the medication is available in 1 mg/0.5 mL concentration. This means that in 0.5 mL, there is 1 mg of vitamin K. Therefore, the nurse should administer 0.5 mL to provide the correct dosage to the newborn.
Summary:
- Choice A: Incorrect, as it does not match the concentration of the medication.
- Choices B-G: Irrelevant as they do not provide the correct calculation based on the medication concentration.
A nurse is providing care for a client who is 2 days postoperative following abdominal surgery and is about to progress from a clear liquid diet to full liquids. Which of the following items should the nurse tell the client he may now request to have on his meal tray?
- A. Chicken broth
- B. Flavored gelatin
- C. Cranberry juice
- D. Skim milk
Correct Answer: D
Rationale: The correct answer is D: Skim milk. Skim milk is allowed on a full liquid diet as it is easily digested and provides essential nutrients. It is also a good source of protein and calcium, important for healing post-surgery. Chicken broth (A) and flavored gelatin (B) are typically allowed on a clear liquid diet but may not be suitable for a full liquid diet. Cranberry juice (C) is acidic and may be too harsh on the stomach post-surgery. Therefore, the nurse should advise the client to choose skim milk for his meal tray to support healing and recovery.
A nurse is presenting a community-based program about HIV and AIDS. A client asks the nurse to describe the initial symptoms experienced with HIV infection. Which of the following manifestations should the nurse include in the explanation of initial symptoms?
- A. Flu-like symptoms and night sweats
- B. Fungal and bacterial infections
- C. Pneumocystis lung infection
- D. Kaposi’s sarcoma
Correct Answer: A
Rationale: The correct answer is A: Flu-like symptoms and night sweats. Initial symptoms of HIV infection often present as flu-like symptoms such as fever, fatigue, sore throat, swollen lymph nodes, and night sweats. This is known as acute retroviral syndrome and occurs within the first few weeks after exposure to the virus. These symptoms are nonspecific and can easily be mistaken for other common illnesses. Fungal and bacterial infections (B), Pneumocystis lung infection (C), and Kaposi’s sarcoma (D) are not initial symptoms of HIV infection. Fungal and bacterial infections typically occur in later stages of HIV when the immune system is severely compromised. Pneumocystis lung infection and Kaposi’s sarcoma are opportunistic infections seen in advanced stages of HIV, usually when the CD4 count is significantly low.