Nokea
The nurse is caring for a client experiencing an exacerbation of rheumatoid arthritis (RA). The nurse should obtain a prescription for
- A. Allopurinol.
- B. Verapamil.
- C. Prednisone.
- D. Methotrexate.
Correct Answer: C, D
Rationale: Prednisone (a corticosteroid) reduces acute inflammation, and methotrexate (a DMARD) manages chronic rheumatoid arthritis. Allopurinol treats gout, and verapamil is for cardiac issues.
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The nurse is caring for a client two days post-op total knee replacement with a continuous passive motion (CPM) device at the bedside. The nurse would recognize that the primary purpose of this machine is to:
- A. Stabilize the knee joint during ambulation
- B. Promote knee flexion
- C. Reduce post-surgical swelling
- D. Prevent blood clots
Correct Answer: B
Rationale: The primary purpose of a CPM device is to promote knee flexion and range of motion post-surgery, aiding recovery. It doesn't stabilize during ambulation, primarily reduce swelling, or prevent clots.
The PACU nurse is caring for a patient who is presenting with agitation following knee replacement surgery. What action should the nurse take first?
- A. Notify the anesthesiologist of the adverse reaction.
- B. Assess the patient's respiratory function.
- C. Obtain an order for additional sedation to keep the patient safe during agitation.
- D. Administer a benzodiazepine antagonist.
Correct Answer: B
Rationale: Assessing respiratory function is the priority, as agitation post-surgery may signal hypoxia, a life-threatening issue. Notifying the anesthesiologist, sedation, and reversal agents are secondary after ruling out airway or breathing problems.
The nurse performs a physical assessment on a client and observes a tremor in the client's hand when their arm is extended. The nurse understands that this finding is consistent with which of the following?
- A. Rheumatic fever
- B. End-stage renal disease
- C. Neuroleptic Malignant Syndrome (NMS)
- D. Human Immunodeficiency Virus (HIV)
Correct Answer: C
Rationale: A tremor with an extended arm (postural tremor) can be consistent with Neuroleptic Malignant Syndrome, a reaction to certain medications causing muscle rigidity and tremors. Other options are less directly linked to this finding.
The nurse in the medical-surgical unit is caring for a newly admitted client.
Item 5 of 6
History and Physical
1930: Client is a 45-year-old male who has a one-and-a-half-week history of pain, redness, and swelling in his right foot. He reported that the symptoms began after he accidentally cut his foot while walking barefoot in his backyard. Over the next few days, he developed pain and swelling around the cut, accompanied by redness and warmth. He went to urgent care two days later and was diagnosed with cellulitis in his right foot. He was prescribed antibiotics but could not afford the treatment. Three days ago, the pain escalated and was described as throbbing and constant, with a severity rating of 7/10 on the Numerical Pain Rating Scale. He states, "the pain is now in the bone of my foot; I don't know how else to describe it." He also noted occasional fever 101°F (38.3°C), chills, and general malaise. On physical examination, his right foot was erythematous, swollen, and warm to the touch. A 3 cm ulcer was noted on the plantar aspect of the right foot, with moderate purulent discharge present. The ulcer appeared deep, and palpation of the surrounding tissue elicited tenderness. There was limited range of motion in the right ankle due to pain. The distal pulses were palpable 2+, and there were signs of neuropathy in the feet (decreased sensation to light touch and pinprick). He has a medical history of uncontrolled diabetes mellitus (type two), obesity, peripheral neuropathy in all extremities, hypertension, hyperlipidemia, and epilepsy.
Orders
2100:
Magnetic resonance imaging of the right foot without contrast
Insert peripheral vascular access device
Laboratory tests: blood culture and sensitivity (C & S), complete blood count (CBC), complete metabolic panel (CMP), lactic acid
vancomycin 1 g, IV, every 12 hours
Wound culture
fentanyl 50 mcg IV, every 5 hours PRN pain
Consultation
Infectious Disease Consultation
2050: Client was evaluated and I strongly suspect osteomyelitis in his right foot. Labs are pending. Agree with admission and will follow closely.
Nurses' Notes
2110: Orders received and reviewed. Vital signs: T 103° F (39.4° C), P 92, RR 18, BP 141/87, pulse oximetry reading 98% on room air. Client reports pain '8' on the Numerical Pain Scale.
The nurse reviews the physician's orders, client's laboratory data, and makes an entry into the nurses' notes. Which of the following actions should the nurse take?
- A. Withhold administering the prescribed antibiotic and notify the physician.
- B. Place a dressing over the client's wound before transporting the client to MRI.
- C. Notify the physician to hold the ordered MRI because of the client's kidney function.
- D. Instruct the client to remove all metal objects before the MRI.
- E. Administer prescribed pain medication before the MRI.
- F. Irrigate the wound with 0.9% sodium chloride (normal saline) before obtaining wound culture.
- G. Request a prescription for a nonsteroidal anti-inflammatory drug.
Correct Answer: B, D, E, F
Rationale: B: A dressing protects the wound during transport. D: Removing metal prevents MRI interference. E: Pain medication improves comfort for MRI. F: Irrigation ensures a clean sample for culture. A and C require more data, and G is not urgent.
The nurse provides discharge instructions to a client with a newly applied fiberglass cast for a fractured radius. Which of the following statements by the client would indicate a correct understanding of the teaching?
- A. The swelling can be reduced by keeping my extremity in a dependent position.'
- B. The edges of the cast can be cut with scissors until I feel comfortable.'
- C. To reduce pain and swelling, I should apply a warm compress.'
- D. If my cast gets slightly wet, pat it dry with a towel and try drying it with a hair dryer set on the cool setting.'
Correct Answer: D
Rationale: Drying a slightly wet fiberglass cast with a towel and a cool hair dryer is appropriate to prevent skin breakdown. A dependent position increases swelling, cutting the cast is unsafe, and warm compresses can worsen swelling and are not recommended.