Nokea
A woman with chronic osteoarthritis is complaining of knee pain. Which pathophysiological process is contributing to her pain?
- A. Inflammation of the synovial membrane.
- B. Degeneration of the cartilage in the joint.
- C. Joint inflammation occurs when chondrocyte injury destroys joint cartilage, producing osteophytes.
- D. Formation of uric acid crystals in the joint space.
Correct Answer: C
Rationale: The correct answer is C. In osteoarthritis, the breakdown of cartilage in the joints leads to chondrocyte injury, which results in the destruction of joint cartilage and the production of osteophytes. This process causes joint inflammation and pain. Choice A is incorrect because osteoarthritis primarily involves the articular cartilage rather than the synovial membrane. Choice B is incorrect as it describes the degeneration of cartilage but does not explain the specific pathophysiological process contributing to pain in osteoarthritis. Choice D is incorrect as the formation of uric acid crystals is characteristic of gout, not osteoarthritis.
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A client admitted to a surgical unit is being evaluated for an intestinal obstruction. The HCP prescribes an NG tube to be inserted and placed on intermittent low wall suction. Which intervention should the nurse implement to facilitate proper tube placement?
- A. Soak the NG tube in warm water
- B. Insert the tube with the client's head tilted back
- C. Apply suction while inserting the tube
- D. Elevate the head of the bed 60 to 90 degrees
Correct Answer: D
Rationale: Elevating the head of the bed 60 to 90 degrees is the correct intervention to facilitate proper placement of the NG tube. This position helps to use gravity to guide the tube smoothly into the gastrointestinal tract. Soaking the NG tube in warm water (Choice A) is not necessary for proper placement. Inserting the tube with the client's head tilted back (Choice B) can cause discomfort and may lead to improper placement. Applying suction while inserting the tube (Choice C) is not recommended as it can cause trauma to the nasal passages and esophagus.
Which finding should the nurse report immediately for a client receiving a blood transfusion?
- A. Mild itching and rash
- B. Temperature increase of 1.5°F (0.8°C)
- C. Heart rate increase of 10 beats per minute
- D. Slight headache
Correct Answer: B
Rationale: A temperature increase of 1.5°F (0.8°C) during a blood transfusion is a significant finding that can indicate a transfusion reaction, such as a febrile non-hemolytic reaction, which can progress to more severe reactions. It is crucial to report this immediately to the healthcare provider for further evaluation and intervention. Mild itching and rash (choice A) are common minor reactions to blood transfusions and can be managed appropriately without immediate concern. An increase in heart rate by 10 beats per minute (choice C) is within an acceptable range and may be a normal compensatory response to the transfusion. A slight headache (choice D) is a common complaint and is not typically associated with severe transfusion reactions; thus, it does not require immediate reporting compared to the temperature increase.
The client with chronic venous insufficiency is being taught about self-care measures. Which instruction should be included?
- A. Avoid wearing compression stockings
- B. Elevate legs above heart level when resting
- C. Apply heat packs to improve circulation
- D. Limit walking to prevent leg pain
Correct Answer: B
Rationale: The correct instruction for a client with chronic venous insufficiency is to elevate their legs above heart level when resting. This position helps reduce venous pressure and edema, improving circulation. Avoiding compression stockings (choice A) is incorrect as they are beneficial in managing chronic venous insufficiency. Applying heat packs (choice C) is not recommended as heat can worsen edema. Limiting walking (choice D) is not advisable as regular, gentle exercise like walking can actually help improve circulation in patients with chronic venous insufficiency.
What is the main characteristic of cystic fibrosis?
- A. Multiple upper respiratory infections
- B. An underproduction of exocrine glands
- C. Excessive, thick mucus
- D. An overproduction of thin mucus
Correct Answer: C
Rationale: The main characteristic of cystic fibrosis is the production of excessive, thick mucus. This thick mucus leads to blockages in the airways, digestive system, and other organs. Choice A is incorrect because while individuals with cystic fibrosis are more prone to respiratory infections, the main characteristic is the mucus production. Choice B is incorrect as cystic fibrosis is characterized by the overproduction, not underproduction, of exocrine glands. Choice D is also incorrect as the mucus produced in cystic fibrosis is thick, not thin.
Which nursing intervention promotes achievement of the goal 'optimal mobility' for a client who had a total hip replacement 8 hours ago?
- A. Encourage the client to use an abductor pillow when ambulating.
- B. Teach the client to perform leg exercises in bed.
- C. Assist the client to sit at the edge of the bed.
- D. Assist the client to turn while an abductor pillow is between the legs.
Correct Answer: D
Rationale: Assisting the client to turn while an abductor pillow is between the legs is the correct intervention to promote optimal mobility for a client who had a total hip replacement 8 hours ago. Using an abductor pillow helps maintain hip alignment and prevents dislocation, which are crucial considerations in the early postoperative period. Encouraging the client to use an abductor pillow when turning is more beneficial compared to the other options: teaching leg exercises in bed, encouraging the use of a walker when ambulating, or assisting the client to sit at the edge of the bed, as these interventions may not directly address the specific needs of a client after a total hip replacement.