Nokea
The nurse performs an assessment on a client newly diagnosed with rheumatoid arthritis. The nurse expects to note which early manifestations of the disease? Select all that apply.
- A. Fatigue
- B. Anorexia
- C. Weakness
- D. Low-grade fever
- E. Joint deformities
- F. Joint inflammation
Correct Answer: A,B,C,D,F
Rationale: Rheumatoid arthritis is a chronic, progressive, systemic inflammatory autoimmune disease process that primarily affects the synovial joints. Early manifestations include fatigue, anorexia, weakness, joint inflammation, low-grade fever, and paresthesia. Joint deformities are late manifestations.
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While preparing to administer an intravenous (IV) medication, the nurse notes that the medication is incompatible with the IV solution. Which intervention should the nurse implement to assure the client's safety?
- A. Ask the provider to prescribe a compatible IV solution.
- B. Start a new IV catheter for the incompatible medication.
- C. Collaborate with the provider for a new administration route.
- D. Flush tubing before and after administering the medication with normal saline.
Correct Answer: D
Rationale: When giving a medication intravenously, if the medication is incompatible with the IV solution, the tubing is flushed before and after the medication with infusions of normal saline to prevent in-line precipitation of the incompatible agents. Starting a new IV, changing the solution, or changing the administration route is unnecessary because a simpler, less risky, viable option exists.
The nurse analyzed an electrocardiogram (ECG) strip (refer to figure) for a client demonstrating left-sided heart failure and interprets the ECG strip as which rhythm?
- A. Atrial fibrillation
- B. Sinus dysrhythmia
- C. Ventricular fibrillation
- D. Third-degree heart block
Correct Answer: A
Rationale: Atrial fibrillation is characterized by rapid, chaotic atrial depolarization. Ventricular rates may be less than 100 beats per minute (controlled) or greater than 100 beats per minute (uncontrolled). The ECG reveals chaotic or no identifiable P waves and an irregular ventricular rhythm. A sinus dysrhythmia has a normal P wave and PR interval and QRS complex. In ventricular fibrillation, there are no identifiable P waves, QRS complexes, or T waves.
The nurse instructs a preoperative client about the proper use of an incentive spirometer. What result should the nurse use to determine that the client is using the incentive spirometer effectively?
- A. Cloudy sputum
- B. Shallow breathing
- C. Unilateral wheezing
- D. Productive coughing
Correct Answer: D
Rationale: Incentive spirometry helps reduce atelectasis, open airways, stimulate coughing, and help mobilize secretions for expectoration, via vital client participation in recovery. Cloudy sputum, shallow breathing, and wheezing indicate that the incentive spirometry is not effective because they point to infection, counterproductive depth of breathing, and bronchoconstriction, respectively.
The nurse performs a neurovascular assessment on a client with a newly applied cast. The nurse should determine that there is a need for close observation and a need for follow-up if which is noted?
- A. Palpable pulses distal to the cast
- B. Capillary refill greater than 6 seconds
- C. Blanching of the nail bed when it is depressed
- D. Sensation when the area distal to the cast is pinched
Correct Answer: B
Rationale: To assess for adequate circulation, the nail bed of each finger or toe is depressed until it blanches, and then the pressure is released. This is known as capillary refill time. Optimally, the color will change from white to pink rapidly (less than 3 seconds). If this does not occur, the toes or fingers will require close observation and follow-up. Palpable pulses and sensations distal to the cast are expected. However, if pulses could not be palpated or if the client complained of numbness or tingling, the primary health care provider should be notified.
The nurse is preparing to care for a client postureterolithotomy who has a ureteral catheter in place. The nurse should plan to implement which action in the management of this catheter when the client arrives from the recovery room?
- A. Clamp the catheter.
- B. Place tension on the catheter.
- C. Check the drainage from the catheter.
- D. Irrigate the catheter using 10 mL sterile normal saline.
Correct Answer: C
Rationale: Drainage from the ureteral catheter should be checked when the client returns from the recovery room and at least every 1 to 2 hours thereafter. The catheter drains urine from the renal pelvis, which has a capacity of 3 to 5 mL. If the volume of urine or fluid in the renal pelvis increases, tissue damage to the pelvis will result from pressure. Therefore, the ureteral tube is never clamped. Additionally, irrigation is not performed unless there is a specific primary health care provider's prescription to do so.