Nokea
To reduce symptoms of early morning stiffness in a ptient who has rheumatoid arthritis, the nurse can encourage the patient to:
- A. take a hot tub bath or shower in the morning
- B. put joints through passive ROM before tryoing to move them actively
- C. sleep with a hot pad
- D. take two aspirins before arising, and wait 15 minutes before attempting locomotion
Correct Answer: A
Rationale: The correct answer is A: take a hot tub bath or shower in the morning. This is effective as the warm water helps to relax muscles and joints, reducing stiffness. It also improves circulation, which can alleviate morning stiffness in patients with rheumatoid arthritis.
Incorrect choices:
B: Putting joints through passive ROM before active movement may exacerbate stiffness if not done properly.
C: Sleeping with a hot pad may provide temporary relief but does not address the root cause of morning stiffness.
D: Taking aspirin can help with pain but does not directly address stiffness. Waiting 15 minutes before moving may not be as effective as soaking in warm water.
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A client with suspected lymphoma is scheduled for lymphangiography. The nurse should inform the client that this procedure may cause which harmless, temporary change?
- A. Purplish stools
- B. Redness of the upper part of the feet
- C. Bluish urine
- D. Coldness of the soles
Correct Answer: B
Rationale: The correct answer is B: Redness of the upper part of the feet. During lymphangiography, a contrast dye is injected into the lymphatic vessels. This may cause temporary redness in the upper part of the feet due to the dye spreading throughout the lymphatic system. Purplish stools (A), bluish urine (C), and coldness of the soles (D) are not expected side effects of lymphangiography and do not have a direct correlation with the procedure.
Which gauge IV cannula should the nurse choose when preparing to initiate a blood transfusion?
- A. 18
- B. 24
- C. 22
- D. 28
Correct Answer: A
Rationale: The correct choice is A: 18 gauge IV cannula for blood transfusion. Larger gauge allows for faster flow rate, crucial for transfusions to prevent clotting. 24, 22, and 28 gauge cannulas are too small for adequate blood flow, leading to potential complications like hemolysis or slowed infusion.
The primary underlying disorder of pulmonary edema is:
- A. Decreased left ventricular pumping
- B. Increased left atrial contractility
- C. Decreased right ventricular elasticity
- D. Increased right atrial pressure
Correct Answer: A
Rationale: Step 1: Pulmonary edema is caused by fluid accumulation in the lungs due to increased pressure in the pulmonary vasculature.
Step 2: Decreased left ventricular pumping leads to congestive heart failure, causing increased pressure in pulmonary circulation.
Step 3: This increased pressure forces fluid from the capillaries into the alveoli, causing pulmonary edema.
Step 4: Increased left atrial contractility (B) would not directly lead to pulmonary edema.
Step 5: Decreased right ventricular elasticity (C) and increased right atrial pressure (D) are not directly related to the pathophysiology of pulmonary edema.
Summary: The correct answer is A because decreased left ventricular pumping directly contributes to the increased pressure in the pulmonary circulation that leads to pulmonary edema. Choices B, C, and D do not align with the primary underlying disorder of pulmonary edema.
The nurse is caring for a patient who has an open wound and is evaluating the progress of wound healing. Which priority action will the nurse take?
- A. Ask the nursing assistive personnel if the wound looks better.
- B. Document the progress of wound healing as “better” in the chart.
- C. Measure the wound and observe for redness, swelling, or drainage.
- D. Leave the dressing off the wound for easier access and more frequent assessments.
Correct Answer: C
Rationale: The correct answer is C because measuring the wound and observing for redness, swelling, or drainage are essential steps in evaluating wound healing progress. Measuring the wound provides objective data on its size changes, while observing for signs of infection like redness, swelling, or drainage helps identify complications.
- Choice A is incorrect because the nursing assistive personnel may not have the necessary knowledge to assess wound healing accurately.
- Choice B is incorrect because documenting progress as "better" without objective data is subjective and does not provide a clear picture of the wound status.
- Choice D is incorrect because leaving the dressing off can expose the wound to contaminants and compromise healing, making it a potentially harmful action.
Of the following information collected during a nursing assessment, which are subjective data?
- A. vomiting, pulse 96
- B. respirations 22, blood pressure 130/80
- C. nausea, abdominal pain
- D. pale skin, thick toenails
Correct Answer: C
Rationale: Subjective data are information reported by the patient that cannot be measured or observed directly. In this case, nausea and abdominal pain are symptoms that can only be described by the patient, making them subjective data. Vomiting, pulse rate, respirations, blood pressure, pale skin, and thick toenails are all objective data, as they can be measured or observed directly by the healthcare provider. Therefore, choice C is the correct answer as it represents subjective data.