Nokea
The nurse is caring for a client with a history of rheumatoid arthritis.
- A. Which symptom is expected in a client with rheumatoid arthritis?
- B. Morning stiffness lasting over 30 minutes.
- C. Pain that worsens with activity.
- D. Asymmetrical joint involvement.
- E. Rapid onset of symptoms.
Correct Answer: A
Rationale: Morning stiffness lasting over 30 minutes is a hallmark of rheumatoid arthritis due to joint inflammation. Pain improves with activity, joints are symmetrically affected, and onset is gradual.
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A patient is admitted to the surgical unit with a diagnosis of rule out inTest inal obstruction.
- A. In which position should the nurse place the patient during insertion of a Salem sump NG tube?
- B. Head of bed elevated 30°-45°.
- C. Head of bed elevated 60°-90°.
- D. Side-lying with head elevated 15°.
- E. Lying flat with head turned to the left side.
Correct Answer: B
Rationale: Elevating the head of the bed to 60°-90° facilitates swallowing and movement of the NG tube through the gastroinTest inal tract, reducing the risk of aspiration and improving patient comfort during insertion. Other positions do not optimize swallowing or tube passage as effectively.
The nurse is caring for a client who is receiving heparin 5,000 units subcutaneously q12h. The nurse should monitor for which of the following as a side effect?
- A. Increased urine output.
- B. Bruising at the injection site.
- C. Elevated blood pressure.
- D. Nausea and vomiting.
Correct Answer: B
Rationale: Heparin can cause bruising at injection sites due to its anticoagulant effect. Options A, C, and D are not typical side effects.
When caring for an abused client, what is most important for the nurse to do initially?
- A. Provide a safe place for the victim
- B. Refer the victim to a long-term support group
- C. Make an appointment with a counselor
- D. Make arrangements for the victim to confront the abuser
Correct Answer: A
Rationale: Providing a safe place is the priority, ensuring immediate protection from further abuse before addressing long-term support.
A spansule is ordered twice a day for a client in the outpatient clinic. What should the nurse teach the client about taking a spansule?
- A. Take the spansule before breakfast and dinner.
- B. If the spansule is difficult to swallow, open it up and put the contents in food.
- C. Spansules should be taken at 12-hour intervals.
- D. Spansules can safely be cut for partial doses.
Correct Answer: C
Rationale: Spansules are time-release capsules, requiring 12-hour intervals for consistent drug release. Opening, cutting, or meal-based timing disrupts their mechanism.
A client with pneumonia.
Which of the following nursing observations would indicate a therapeutic response to the treatment?
- A. Oral temperature of 101°F (38.3°C), increased chest pain with nonproductive cough.
- B. Cough, productive of thick green sputum, client reports feeling tired.
- C. Respirations at 20 with no complaints of dyspnea, moderate amount of thin white sputum.
- D. White cell count of 10,000 mm³, urine output at 40 cc per hour, decreasing amount of sputum.
Correct Answer: C
Rationale: Strategy: Determine which answer choice indicates an improved respiratory status. (1) validates the continued presence of the infection (2) validates the continued presence of the infection (3) correct-sputum characteristics indicate a decrease in the pneumonia; is supported by respiratory status (4) does not substantiate the status of the infection