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A nurse is planning care for a client who has pernicious anemia. Which of the following interventions should the nurse plan to implement?
- A. Vitamin B supplements.
- B. Iron supplements.
- C. Vitamin B12 injections.
- D. Blood transfusions.
Correct Answer: C
Rationale: The correct answer is C: Vitamin B12 injections. Pernicious anemia is caused by a lack of intrinsic factor necessary for Vitamin B12 absorption. Vitamin B12 injections bypass the need for intrinsic factor, ensuring the client receives an adequate amount of the vitamin. Iron supplements (B) are not effective in treating pernicious anemia as it is not related to iron deficiency. Vitamin B supplements (A) may not be absorbed effectively due to the lack of intrinsic factor. Blood transfusions (D) may be used for severe cases of anemia, but they do not address the underlying Vitamin B12 deficiency in pernicious anemia.
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A nurse in a clinic is caring for a female client who has a new diagnosis of acne vulgaris on her cheeks. Which of the following should the nurse include in the teaching plan for this client?
- A. Use friction when washing the affected area.
- B. Use a new cosmetic pad with each limited application of makeup.
- C. Use an oil-based soap to wash affected areas daily.
- D. Express the larger comedones periodically.
Correct Answer: B
Rationale: The correct answer is B: Use a new cosmetic pad with each limited application of makeup. This is important to prevent the spread of bacteria and reduce the risk of exacerbating acne. Using a new pad each time helps to avoid introducing more bacteria to the skin. Choice A is incorrect because friction can irritate the skin and worsen acne. Choice C is incorrect as oil-based soap can clog pores and worsen acne. Choice D is incorrect because expressing comedones can lead to scarring and infection. It's crucial to provide accurate and evidence-based information to clients to promote effective management of their condition.
A nurse is monitoring the fluid replacement of a client who has sustained burns. The nurse should administer which of the following fluids in the first 24 hours following a burn injury?
- A. Dextrose 5% in water.
- B. 0.45% sodium chloride.
- C. Dextrose 5% in 0.9% sodium chloride.
- D. Lactated Ringers.
Correct Answer: D
Rationale: The correct answer is D: Lactated Ringers. In the first 24 hours following a burn injury, it is crucial to administer isotonic solutions like Lactated Ringers to replace lost fluids and electrolytes effectively. Lactated Ringers contain electrolytes like sodium, potassium, and chloride, which help maintain proper fluid balance and prevent dehydration. Dextrose 5% in water (Choice A) is a hypotonic solution and may lead to fluid shifts, worsening the condition. 0.45% sodium chloride (Choice B) is hypotonic and may not provide enough electrolytes for proper fluid replacement. Dextrose 5% in 0.9% sodium chloride (Choice C) may not provide adequate electrolytes compared to Lactated Ringers.
A nurse is assessing a client who has rheumatoid arthritis. Which of the following findings should the nurse expect?
- A. Unilateral joint involvement.
- B. Ulnar deviation.
- C. Decreased sedimentation rate.
- D. Fractures of the spine.
Correct Answer: B
Rationale: The correct answer is B: Ulnar deviation. In rheumatoid arthritis, ulnar deviation of the fingers is a common finding due to inflammation and destruction of the joints. This deformity leads to the fingers deviating towards the ulnar side of the hand. This is a characteristic feature seen in rheumatoid arthritis and is caused by the inflammation affecting the joints. Choices A, C, and D are incorrect. A: Unilateral joint involvement is not typical of rheumatoid arthritis, as it usually affects multiple joints symmetrically. C: Decreased sedimentation rate is not expected in rheumatoid arthritis, as it is typically associated with an elevated sedimentation rate due to inflammation. D: Fractures of the spine are not a common finding in rheumatoid arthritis, as it primarily affects the joints.
A nurse is caring for a client who is cognitively impaired and repeatedly pulls on his NG tube. Which of the following actions should the nurse take before requesting a prescription for restraints? (Select all that apply.)
- A. Provide diversionary activities for the client.
- B. Assist the client with toileting at frequent intervals.
- C. Involve the family in the client’s care.
- D. Explain to the client that he will be restrained if he does not stop pulling on his NG tube.
- E. Use an electronic bed alarm device.
Correct Answer: A,B,C,E
Rationale: The correct actions are A, B, C, and E. A) Providing diversionary activities can distract the client from pulling on the NG tube. B) Assisting with toileting at frequent intervals helps address any discomfort or restlessness that may be contributing to the behavior. C) Involving the family can provide additional support and understanding of the client's needs. E) Using an electronic bed alarm device can alert the nurse when the client is attempting to pull on the NG tube, allowing for timely intervention. These actions focus on addressing the underlying reasons for the behavior and ensuring the client's safety without resorting to restraints, which should be a last resort due to ethical and legal considerations.
A client seeks medical attention for intermittent signs and symptoms that suggest a diagnosis of Raynaud’s disease. The nurse should assess the trigger of these signs/symptoms by asking which?
- A. Does drinking coffee or ingesting chocolate seem related to the episodes?
- B. Does being exposed to heat seem to cause the episodes?
- C. Do the signs and symptoms occur while you are asleep?
- D. Have you experienced any injuries that have limited your activity levels lately?
Correct Answer: A
Rationale: The correct answer is A: Does drinking coffee or ingesting chocolate seem related to the episodes? This question is relevant because caffeine and chocolate are known triggers for Raynaud's disease due to their vasoconstrictive properties. By asking about these specific triggers, the nurse can gather important information to help identify potential causes of the client's symptoms.
Choice B is incorrect because exposure to heat typically alleviates symptoms of Raynaud's disease rather than causing them. Choice C is irrelevant as Raynaud's symptoms typically occur when the individual is exposed to cold or experiencing stress, not while asleep. Choice D is also incorrect as injuries limiting activity levels are not directly related to Raynaud's disease triggers.