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An older adult client, at risk for osteoporosis, reports taking a multivitamin daily. In developing a teaching plan for the client, which follow- up Information should the nurse obtain?
- A. What time of day the multivitamin is taken.
- B. The amount of calcium in the multivitamin.
- C. Usual activity after taking the multivitamin.
- D. If the multivitamin is taken with a meal or snack
Correct Answer: B
Rationale: Confirming calcium content in the multivitamin ensures adequate intake for bone health, critical for osteoporosis prevention.
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A client with an acute exacerbation of rheumatoid arthritis (RA) has localized pain and inflammation of the fingers and feet, swelling, redness, restricted joint motion, and reports feeling fatigued. Which nursing problem has the highest priority for this client?
- A. Fatigue related to disease exacerbation.
- B. Pain related to joint inflammation
- C. Impaired physical mobility related to joint pain.
- D. Self-care deficit related to disease progression.
Correct Answer: B
Rationale: Pain is the primary symptom of RA exacerbation, impacting quality of life and requiring immediate management.
The healthcare provider prescribes cefazolin 800 mg IM every six hours. The available vial is labeled, 'Cefazolin 1 gram,' and the instructions for reconstitution state, For IM use add 2.5 mL sterile water for Injection to provide a total volume of 3.0 mL. After reconstitution, the solution contains how many mg/mL? Enter numeric value only. If rounding is required, round to the nearest whole number.)
Correct Answer: 333
Rationale: One gram (1000 mg) reconstituted in 3.0 mL yields a concentration of 1000 mg / 3 mL = 333.33 mg/mL, rounded to 333 mg/mL.
Nurses' Notes
Assessment is completed. The nurse notes that the nail angle is 180 degrees when viewed from the side and is spongy when palpated.
The nurse reviews client data. Select the 3 possible conditions that could have the clinical manifestation of clubbed nails for this client.
- A. Pneumonia
- B. Lung cancer
- C. Flu
- D. Chronic obstructive pulmonary disease (COPD)
- E. Chronic bronchitis
Correct Answer: B,E
Rationale: Lung cancer and chronic bronchitis are associated with clubbed nails due to chronic hypoxemia, unlike pneumonia or flu.
Which nursing action is most helpful in promoting circulation in a client with chronic venous insufficiency?
- A. Limit intake of chips and pretzels.
- B. Encourage mountain biking.
- C. Elevate lower extremities.
- D. Restrict fluid intake to water.
Correct Answer: C
Rationale: Elevating lower extremities reduces venous pressure and promotes blood return, directly improving circulation in chronic venous insufficiency.
A client with pancreatitis is receiving 0.9% normal saline, and the prescribed IV infusion rate was increased from 100 mL/hour to 150 mL/hour. Which assessment finding indicates to the nurse that the prescription has a therapeutic outcome?
- A. An increase in the hematocrit (HCT) from 42% (0.42 volume fraction) to 52% (0.52 volume fraction).
- B. An increase in the blood glucose level from 130 mg/dl. (7.22 mmol/L).
- C. A decrease in blood urea nitrogen (BUN) from 36 mg/dL (12.9 mmol/L) to 23 mg/dL (8.21 mmol/L).
- D. A decrease in serum amylase from 24 units/dl (240 units) to 12 units/dl. (120 units/L);
Correct Answer: C
Rationale: A decrease in BUN indicates improved renal perfusion, a therapeutic outcome of increased IV fluids. Increased hematocrit suggests fluid volume deficit, increased blood glucose is undesirable, and amylase decrease is not directly related to fluid increase.