A nurse is assigned a client with an acute exacerbation of rheumatoid arthritis. Which
medical facts about RA are essential in developing a plan of care. Select all that apply.
A.Onset is acute and usually occurs between 20 and 40
B.The client experiences stiff, swollen joints bilaterally
C.The client may no exercise once the disease is diagnosed.
D.Erythrocyte sedimentation rate (ESR) is elevated, and xrays show erosions and
decalcification of involved joints
E.Inflamed cartilage triggers compliment activation, which stimulates the release of
additional inflammatory mediators
F.The first line treatment is gold salts and methotrexate
Give this one a try later!
Rationale B, D, E starts insidiously between 35-50, maintaining ROM is
essential, NSAIDS and salicylates are first line. Many drug that decrease
immune system (methotrexate) cause flu like s/s and are not well tolerated.
,The client's serum potassium level is elevated in acute renal failure, and the nurse
administers sodium polystyrene sulfonate (Kayexalate). What is the action of this
drug?
A.Increase potassium excretion from the colon
B.Release hydrogen ions for sodium ions
C.Increase calcium absorption in the colon
D.Exchange sodium for potassium ions in the colon
Give this one a try later!
Rationale D- Kayexelate causes the body to excrete potassium through the
GI tract. The sodium of the resin is particularly replaced by potassium. The
potassium is then eliminated when the resin is eliminated with feces.
A client's stools are light gray in color. The nurse should assess the client further for
which of the following? (Select all that apply)
A.Intolerance to fatty foods
B.Fever
C.Jaundice
D.Respiratory distress
E.Pain at McBurney's point
F.Peptic ulcer disease
Give this one a try later!
, Rationale: A, B, C Bile duct obstruction will cause gray colored stools as
bile is unable to get through to give color to stool. Other symptoms are
RUQ pain, jaundice from elevated serum bilirubin, fever from inflammation
or infection of gallbladder. McBurney's point is lower abdomen and
associated with appendicitis. Bleeding ulcer produces black stool and
respiratory distress is not a symptom of cholelithiasis.
A nurse receives the change of shift report assigned clients and prioritizes client
rounds. In what order should the nurse assess these clients?
A.A client with an endotracheal tube transferred out of intensive care today
B.A client with type 2 diabetes who had a cerebral vascular accident 4 days ago
C.A client with cellulitis of the left lower extremity with a fever of 100.8F
D.A client receiving D5W IV at 125 mL with 75 mL remaining.
Give this one a try later!
Rationale A, C, D, B
The client with TB is to be discharged home with community health nursing follow up.
Of the following nursing interventions, which should have the highest priority?
A.Offering the client emotional support
B.Teaching the client about the disease and its treatment
C.Coordinating various agency services
D.Assessing the clients environment for sanitation
Give this one a try later!
Rationale: B- teaching importance of compliance with medication, long
term medication use.
medical facts about RA are essential in developing a plan of care. Select all that apply.
A.Onset is acute and usually occurs between 20 and 40
B.The client experiences stiff, swollen joints bilaterally
C.The client may no exercise once the disease is diagnosed.
D.Erythrocyte sedimentation rate (ESR) is elevated, and xrays show erosions and
decalcification of involved joints
E.Inflamed cartilage triggers compliment activation, which stimulates the release of
additional inflammatory mediators
F.The first line treatment is gold salts and methotrexate
Give this one a try later!
Rationale B, D, E starts insidiously between 35-50, maintaining ROM is
essential, NSAIDS and salicylates are first line. Many drug that decrease
immune system (methotrexate) cause flu like s/s and are not well tolerated.
,The client's serum potassium level is elevated in acute renal failure, and the nurse
administers sodium polystyrene sulfonate (Kayexalate). What is the action of this
drug?
A.Increase potassium excretion from the colon
B.Release hydrogen ions for sodium ions
C.Increase calcium absorption in the colon
D.Exchange sodium for potassium ions in the colon
Give this one a try later!
Rationale D- Kayexelate causes the body to excrete potassium through the
GI tract. The sodium of the resin is particularly replaced by potassium. The
potassium is then eliminated when the resin is eliminated with feces.
A client's stools are light gray in color. The nurse should assess the client further for
which of the following? (Select all that apply)
A.Intolerance to fatty foods
B.Fever
C.Jaundice
D.Respiratory distress
E.Pain at McBurney's point
F.Peptic ulcer disease
Give this one a try later!
, Rationale: A, B, C Bile duct obstruction will cause gray colored stools as
bile is unable to get through to give color to stool. Other symptoms are
RUQ pain, jaundice from elevated serum bilirubin, fever from inflammation
or infection of gallbladder. McBurney's point is lower abdomen and
associated with appendicitis. Bleeding ulcer produces black stool and
respiratory distress is not a symptom of cholelithiasis.
A nurse receives the change of shift report assigned clients and prioritizes client
rounds. In what order should the nurse assess these clients?
A.A client with an endotracheal tube transferred out of intensive care today
B.A client with type 2 diabetes who had a cerebral vascular accident 4 days ago
C.A client with cellulitis of the left lower extremity with a fever of 100.8F
D.A client receiving D5W IV at 125 mL with 75 mL remaining.
Give this one a try later!
Rationale A, C, D, B
The client with TB is to be discharged home with community health nursing follow up.
Of the following nursing interventions, which should have the highest priority?
A.Offering the client emotional support
B.Teaching the client about the disease and its treatment
C.Coordinating various agency services
D.Assessing the clients environment for sanitation
Give this one a try later!
Rationale: B- teaching importance of compliance with medication, long
term medication use.
