Nokea
The client diagnosed with RA is being seen in the outpatient clinic. Which preventive care should the nurse include in the regularly scheduled clinic visits?
- A. Perform joint x-rays to determine progression of the disease.
- B. Send blood to the laboratory for an erythrocyte sedimentation rate.
- C. Recommend the flu and pneumonia vaccines.
- D. Assess the client for increasing joint involvement.
Correct Answer: C
Rationale: Flu and pneumonia vaccines prevent infections, critical in RA due to immunosuppression. X-rays, ESR, and joint assessments are diagnostic, not preventive.
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The nurse is caring for the client diagnosed with acquired immunodeficiency syndrome (AIDS) dementia. Which action by the unlicensed assistive personnel (UAP) requires immediate intervention by the nurse?
- A. The UAP is helping the client to sit on the bedside chair.
- B. The UAP is wearing sterile gloves when bathing the client.
- C. The UAP is helping the client shave and brush the teeth.
- D. The UAP is providing a back massage to the client.
Correct Answer: B
Rationale: Sterile gloves are unnecessary for bathing, risking improper technique. Sitting, shaving, and massage are appropriate UAP tasks.
The client admitted with rule-out Guillain-Barré syndrome has just had a lumbar puncture. Which intervention should the nurse implement postprocedure?
- A. Monitor the client for hypotension.
- B. Apply pressure to the puncture site.
- C. Test the client's cerebrospinal fluid.
- D. Increase the client's fluid intake.
Correct Answer: D
Rationale: Increasing fluid intake post-lumbar puncture prevents spinal headache. Hypotension is not a primary concern, pressure is applied during the procedure, and CSF testing is lab-based.
The charge nurse observes the primary nurse interacting with a client. Which action by the primary nurse warrants immediate intervention by the charge nurse?
- A. The nurse explains the IVP diuretic will make the client urinate.
- B. The nurse dons nonsterile gloves to remove the client's dressing.
- C. The nurse administers a medication without checking for allergies.
- D. The nurse asks the UAP for help moving a client up in bed.
Correct Answer: C
Rationale: Administering medication without checking allergies risks allergic reactions, requiring immediate intervention. Diuretic explanation, glove use, and UAP assistance are appropriate.
The male client diagnosed with multiple sclerosis states he has been investigating alternative therapies to treat his disease. Which intervention is most appropriate by the nurse?
- A. Encourage the therapy if it is not contraindicated by the medical regimen.
- B. Tell the client only the health-care provider should discuss this with him.
- C. Ask how his significant other feels about this deviation from the medical regimen.
- D. Suggest the client research an investigational therapy instead.
Correct Answer: A
Rationale: Encouraging safe alternative therapies supports autonomy if they align with medical treatment. Deferring to HCP, involving significant other, or suggesting investigational therapies are less appropriate.
The client diagnosed with myasthenia gravis is admitted with an acute exacerbation. Which interventions should the nurse implement? Select all that apply.
- A. Assist the client to turn and cough every two (2) hours.
- B. Place the client in a high or semi-Fowler's position.
- C. Assess the client's pulse oximeter reading every shift.
- D. Plan meals to promote medication effectiveness.
- E. Monitor the client's serum anticholinesterase levels.
Correct Answer: A,B,C,D
Rationale: Turning/coughing, Fowler’s position, pulse oximetry, and meal timing address respiratory risk and medication efficacy in myasthenia gravis. Serum anticholinesterase levels are not routinely monitored.