Nokea
The client tells the nurse, 'My father is furious with me. He does not want me to ride a motorcycle.' Which response by the nurse is most appropriate?
- A. As they say, 'Father knows best.''
- B. I'll be sure it is a safe.'
- C. It can be frustrating when you disagree with your father.'
- D. I think you should obey your father's wishes.'
Correct Answer: C
Rationale: Acknowledging the client's frustration validates their feelings without judgment, fostering therapeutic communication. The other responses either dismiss the client's emotions or impose the nurse's opinion, which is inappropriate.
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The client with rheumatoid arthritis is to receive prednisone 2.5 mg P.D. before meals and at bedtime. What is the primary expected action of the drug?
- A. Maintenance of sodium and potassium balance
- B. Improvement of carbohydrate metabolism
- C. Production of androgen-like effects
- D. Interference with inflammatory reactions
Correct Answer: D
Rationale: Prednisone's primary action in rheumatoid arthritis is to interfere with inflammatory reactions, reducing joint inflammation.
Which assessment finding would the nurse consider a likely adverse effect of the client's methotrexate (Rheumatrex) therapy?
- A. Constipation
- B. Arrhythmia
- C. Mouth sores
- D. Chest pain
Correct Answer: C
Rationale: Mouth sores (stomatitis) are a common adverse effect of methotrexate due to its impact on rapidly dividing cells, like those in the oral mucosa. The other symptoms are less commonly associated.
The client is being seen in the clinic for a second-degree ankle sprain. Which treatments should the nurse plan?
- A. Rest, elevate the extremity, apply ice intermittently, and apply a compression bandage.
- B. Do range of motion to determine the extent of injury, apply heat, and check circulation.
- C. Use moist heat and then apply ice; check circulation, motion, and sensation; and elevate.
- D. Refer to an orthopedic surgeon, apply ice, give an analgesic, elevate, and encourage rest.
Correct Answer: A
Rationale: A. Rest prevents further injury and promotes healing. Ice and elevation control swelling. Compression with an elastic bandage controls bleeding, reduces edema, and provides support for injured tissues.
The nurse is administering 0730 medications to clients on a medical orthopedic unit. Which medication should be administered first?
- A. The daily cardiac glycoside to a client diagnosed with back pain and heart failure.
- B. The routine insulin to a client diagnosed with neck strain and type 1 diabetes.
- C. The oral proton pump inhibitor to a client scheduled for a laminectomy this a.m.
- D. The fourth dose of IV antibiotic for a client diagnosed with a surgical infection.
Correct Answer: B
Rationale: Insulin for type 1 diabetes prevents hyperglycemia, a life-threatening risk, and takes priority. Cardiac glycoside, PPI, and antibiotics are important but less urgent.
The nurse is reviewing the serum laboratory results of the client with DM prior to surgical removal of pins used to stabilize a compound ankle fracture. Based on the results, which action should the nurse take?
- A. Notify the surgeon because the white blood cell count is elevated.
- B. Notify the anesthesiologist because multiple lab values are abnormal.
- C. Give potassium chloride 10 mEq in 100 mL NaCl per agency protocol.
- D. Continue to prepare the client for the scheduled pin removal surgery.
Correct Answer: A
Rationale: A. The elevated WBC indicates that the client may have an infection, which increases the risk of developing osteomyelitis. DM and a compound fracture also increase the client's risk for osteomyelitis.