Nokea
The nurse reviews the client's clinical data. Which action should the nurse take based on the clinical data?
- A. Administer the prescribed ketorolac
- B. Remove the heating pad from the client's lower back
- C. Contact the physician to question the prescription of ketorolac
- D. Reposition the client to the side of the bed and have them twist from side to side
- E. Remove and discard the prescribed fentanyl patch because of its lack of efficacy
Correct Answer: B
Rationale: Removing the heating pad is appropriate, as heat can worsen inflammation or strain in low back pain. Ketorolac may be suitable, twisting risks harm, and fentanyl efficacy needs more data before removal.
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The nurse is caring for a client following a knee arthroscopy procedure. Which of the following assessments should be the priority?
- A. Wound and skin integrity
- B. Mobility assessment
- C. Skin and vascular assessment
- D. Circulation and sensation
Correct Answer: D
Rationale: Circulation and sensation are the priority post-arthroscopy to detect neurovascular compromise, such as nerve damage or impaired blood flow, which can be urgent. Wound, mobility, and skin are important but secondary.
The nurse reviews newly prescribed medications from the primary healthcare provider (PHCP). The nurse understands that the prescribed etanercept is intended to treat which condition?
- A. Osteoarthritis
- B. Diabetes mellitus
- C. Infective endocarditis (IE)
- D. Rheumatoid arthritis
Correct Answer: D
Rationale: Etanercept is a tumor necrosis factor (TNF) inhibitor used to treat autoimmune conditions like rheumatoid arthritis by reducing inflammation and joint damage. Osteoarthritis is not autoimmune, diabetes mellitus affects glucose metabolism, and infective endocarditis is a bacterial infection, none of which are treated with etanercept.
The nurse is planning a staff development conference regarding contractures. Which of the following information should the nurse include? Select all that apply.
- A. Range-of-motion exercises of the extremities help prevent contractures.
- B. Splinting the extremities may increase the risk of contractures.
- C. Too many pillows under the head may cause a neck flexion contracture.
- D. Using multiple staff members to reposition a client may prevent a contracture.
- E. Contractures after a hip arthroplasty can be prevented with an abduction pillow.
Correct Answer: A, C, E
Rationale: Range-of-motion exercises maintain joint flexibility and help prevent contractures. Too many pillows under the head can cause the neck to remain flexed, increasing the risk of a flexion contracture. An abduction pillow keeps the legs properly aligned and prevents adduction contractures after hip surgery.
A client with a history of statin use presents to the clinic with complaints of muscle weakness and pain. The nurse suspects myopathy. Which of the following laboratory tests should the nurse prioritize to evaluate for muscle damage?
- A. Electrocardiogram (ECG)
- B. Liver function tests (LFTs)
- C. Creatine kinase (CK)
- D. Complete blood count (CBC)
Correct Answer: C
Rationale: Creatine kinase (CK) levels rise with muscle damage, common in statin-induced myopathy. ECG is for cardiac issues, LFTs monitor liver, and CBC is not specific to muscle damage.
The nurse is caring for a client with myasthenia gravis who is six hours postoperative following a thymectomy. Which item should the nurse have at the bedside?
- A. Calcium gluconate
- B. Bag-valve mask
- C. Tracheostomy kit
- D. Atropine sulfate
Correct Answer: B
Rationale: Myasthenia gravis can cause respiratory muscle weakness, and post-thymectomy risks respiratory compromise. A bag-valve mask is critical for emergency ventilation. Calcium gluconate, tracheostomy kits, and atropine are not directly related.