Nokea
While assessing a client with degenerative joint disease, the nurse observes Heberden's nodes, large prominences on the client's fingers that are reddened. The client reports that the nodes are painful. Which action should the nurse take?
- A. Review the client's dietary intake of high protein foods
- B. Notify the healthcare provider of the finding immediately
- C. Discuss approaches to chronic pain control with the client
- D. Assess the client's radial pulses and capillary refill time
Correct Answer: C
Rationale: Discussing approaches to chronic pain control is the most appropriate action in this situation as it helps the client manage the chronic pain associated with Heberden's nodes. Reviewing the client's dietary intake of high protein foods (Choice A) is not directly related to managing the pain caused by Heberden's nodes. Notifying the healthcare provider immediately (Choice B) may not be necessary unless there are urgent complications. Assessing the client's radial pulses and capillary refill time (Choice D) is important but not the priority in addressing the client's reported pain and the presence of Heberden's nodes.
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Which instruction should be included in the discharge teaching plan for a client who has had a cataract extraction today?
- A. Use a metal eye shield on the operative eye during the day.
- B. Administer eye ointment after applying eye drops.
- C. Light housekeeping is safe to do, but avoid heavy lifting.
- D. Refrain from sexual activities until follow-up appointment.
Correct Answer: C
Rationale: The correct instruction to include in the discharge teaching plan for a client who has had a cataract extraction is that light housekeeping is safe to do, but heavy lifting should be avoided to prevent increased intraocular pressure. Choice A is incorrect as the eye shield is usually worn at night to protect the eye. Choice B is incorrect as eye ointment is usually applied after eye drops to avoid washing away the ointment. Choice D is incorrect as sexual activities should be avoided until the follow-up appointment to prevent complications.
The nurse is completing the preoperative assessment of a client who is scheduled for a laparoscopic cholecystectomy under general anesthesia. Which finding warrants notification of the HCP prior to proceeding with the scheduled procedure?
- A. Light yellow coloring of the client's skin and eyes.
- B. The client's blood pressure reading of 184/88 mm Hg.
- C. The client vomits 20 ml of clear yellowish fluid.
- D. The IV insertion site is red, swollen, and leaking IV fluid.
Correct Answer: B
Rationale: The correct answer is B. A blood pressure reading of 184/88 mm Hg indicates hypertension, which can increase the risks associated with surgery. The healthcare provider should be notified to manage the blood pressure before proceeding with the scheduled procedure. Choices A, C, and D are incorrect: A, light yellow coloring of the client's skin and eyes may indicate jaundice, but it is not an immediate concern for the scheduled procedure; C, vomiting clear yellowish fluid may suggest bile reflux, but it does not pose an immediate risk to the procedure; D, red, swollen, and leaking IV insertion site indicates a local complication that requires intervention but does not have a direct impact on proceeding with the scheduled surgery.
The nurse is caring for a client with myasthenia gravis. Which symptom is most important for the nurse to report to the healthcare provider?
- A. Diplopia (double vision)
- B. Difficulty swallowing
- C. Weakness in the legs
- D. Fatigue
Correct Answer: B
Rationale: In a client with myasthenia gravis, difficulty swallowing is the most crucial symptom to report to the healthcare provider. This is because it can lead to aspiration, a severe complication in these clients. Diplopia (double vision) and weakness in the legs are common symptoms of myasthenia gravis but are not as immediately dangerous as difficulty swallowing. Fatigue is also a common symptom in myasthenia gravis but does not pose the same risk of aspiration as difficulty swallowing.
The healthcare provider prescribes Cytovene 375 mg every 12 hours to infuse over 90 minutes. The pharmacy delivers Cytovene 375 mg in a 150 mL IV bag. How many ml/hour should the nurse program the infusion pump?
- A. 50 ml/hour.
- B. 75 ml/hour.
- C. 100 ml/hour.
- D. 125 ml/hour.
Correct Answer: C
Rationale: To infuse 150 mL over 90 minutes, the pump should be set to 100 ml/hour (150 mL / 1.5 hours). This rate ensures that the medication is delivered at the proper rate as prescribed. Choices A, B, and D are incorrect because they do not reflect the correct calculation based on the volume of the IV bag and the infusion duration provided in the question.
A client with urolithiasis is preparing for discharge after lithotripsy. Which intervention should the nurse include in the client's postoperative discharge instructions?
- A. Report when hematuria becomes pink-tinged
- B. Use incentive spirometer
- C. Restrict physical activities
- D. Monitor urinary stream for a decrease in output
Correct Answer: D
Rationale: After lithotripsy, monitoring the urinary stream for a decrease in output is essential to identify any potential complications such as urinary retention or obstruction. Reporting pink-tinged hematuria is important, but monitoring the urinary stream for a decrease in output takes precedence as it directly assesses renal function and potential complications. Using an incentive spirometer is not directly related to post-lithotripsy care. Restricting physical activities may be necessary initially but is not the priority compared to monitoring urinary output.