Nokea
The client recently diagnosed with rheumatoid arthritis is prescribed aspirin, a nonsteroidal anti-inflammatory medication. Which comment by the client warrants immediate intervention by the nurse?
- A. I always take the aspirin with food.
- B. If I have dark stools, I will call my HCP.
- C. Aspirin will not cure my arthritis.
- D. I am having some ringing in my ears.
Correct Answer: D
Rationale: Ringing in the ears (tinnitus) indicates aspirin toxicity, requiring immediate intervention. Taking with food, reporting dark stools, and understanding no cure are correct.
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The client diagnosed with SLE is being discharged from the medical unit. Which discharge instructions are most important for the nurse to include? Select all that apply.
- A. Use a sunscreen of SPF 30 or greater when in the sunlight.
- B. Notify the HCP immediately when developing a low-grade fever.
- C. Some dyspnea is expected and does not need immediate attention.
- D. The hands and feet may change color if exposed to cold or heat.
- E. Explain the client can be cured with continued therapy.
Correct Answer: A,B,D
Rationale: Sunscreen, fever reporting, and Raynaud’s phenomenon awareness prevent SLE flares and complications. Dyspnea requires attention, and SLE is not curable.
The primary nurse is administering medications to the assigned clients. Which client situation requires immediate intervention by the charge nurse?
- A. The client with congestive heart failure with an apical pulse of 64 who received 0.125 mg digoxin, a cardiac glycoside.
- B. The client with essential hypertension who received a beta blocker and has a blood pressure of 114/80.
- C. The client with myasthenia gravis who received the anticholinesterase medication 30 minutes late.
- D. The client with AIDS who received trimethoprim-sulfamethoxazole, an antibiotic, and has a CD4 cell count of less than 200.
Correct Answer: C
Rationale: A 30-minute delay in anticholinesterase for myasthenia gravis risks muscle weakness exacerbation, requiring intervention. Digoxin, beta blocker, and antibiotic administration are appropriate.
Which assessment data should make the nurse suspect the client has chronic allergies?
- A. Jaundiced sclera and jaundiced palms of hands.
- B. Pale, boggy, edematous nasal mucosa.
- C. Lacy white plaques on the oral mucosa.
- D. Purple or blue patches on the face.
Correct Answer: B
Rationale: Pale, boggy, edematous nasal mucosa indicates chronic allergic rhinitis. Jaundice, oral plaques, and facial patches suggest other conditions.
The client with myasthenia gravis is undergoing plasmapheresis at the bedside. Which assessment data warrant immediate intervention?
- A. The client's BP is 94/60 and AP is 112.
- B. Negative Chvostek's and Trousseau's signs.
- C. The serum potassium level is 3.5 mEq/L.
- D. Ecchymosis at the vascular site access.
Correct Answer: A
Rationale: Hypotension (BP 94/60) and tachycardia (AP 112) during plasmapheresis suggest hypovolemia or reaction, requiring immediate intervention. Negative signs, normal potassium, and ecchymosis are less urgent.
Which statement by the client supports the diagnosis of Guillain-Barré syndrome?
- A. I just returned from a short trip to Japan.
- B. I had a really bad cold just a few weeks ago.
- C. I think one of the people I work with had this.
- D. I have been taking some herbs for more than a year.
Correct Answer: B
Rationale: A recent viral infection (e.g., cold) is a common trigger for Guillain-Barré syndrome. Travel, coworker illness, and herbs are less relevant.