A nurse works in the rheumatology clinic and sees clients with rheumatoid arthritis
(RA). Which client should the nurse see first?
a. Client who reports jaw pain when eating
b. Client with a red, hot, swollen right wrist
c. Client who has a puffy-looking area behind the knee
d. Client with a worse joint deformity since the last visit
Give this one a try later!
ANS: B
All of the options are possible manifestations of RA. However, the presence
of one joint that is much redder, hotter, or more swollen that the other
joints may indicate infection. The nurse needs to see this client first.
The nurse is caring for a client with osteoarthritis (OA) in the left knee. What factor
does the nurse suspect is the most likely cause of this client's OA?
,a. Trauma to the joint
b. Aging
c. Osteoporosis
d. Familial history
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a. Trauma to the joint
A student nurse asks the faculty to explain best practices when communicating with a
person from the lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ)
community. What answer by the faculty is most accurate?
a. Avoid embarrassing the client by asking questions.
b. Dont make assumptions about their health needs.
c. Most LGBTQ people do not want to share information.
d. No differences exist in communicating with this population.
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ANS: B
Many members of the LGBTQ community have faced discrimination from
health care providers and may be reluctant to seek health care. The nurse
should never make assumptions about the needs of members of this
population. Rather, respectful questions are appropriate. If approached
with sensitivity, the client with any health care need is more likely to answer
honestly.
Which assessments are most important for the nurse to perform to prevent harm on a
client with a sodium level of 118 mEq/L (mmol/L)? (Select all that apply.)
a. Testing skin turgor
,b. Asking about any abdominal pain
c. Assessing cognition
d. Checking deep tendon reflexes
e. Monitoring urine output
f. Checking for the presence of fever
Give this one a try later!
c. Assessing cognition
e. Monitoring urine output
The serum sodium is extremely low, which makes depolarization slower and
cell membranes less excitable. It also can cause cerebral edema to form,
leading to confusion and seizure activity. When sodium levels become very
low, coma and death may occur. Assessing cognition and checking deep
tendon reflexes are the most important assessment data to obtain.
Monitoring urine output needs to be done but is not the priority action in
this situation. Assessing skin turgor, presence of abdominal pain, and fever
are not an urgent assessment to prevent immediate harm.
Which actions are considered best practices for the nurse to use during the
administration of parenteral potassium to a client with a serum potassium level of 1.9
mEq/L (mmol/L) (Select all that apply.)
a. Keeping the client NPO during drug treatment
b. Pushing the drug as a bolus slowly over 5 minutes
c. Using an IV controller to deliver the drug
d. Checking IV access for blood return after the infusion
e. Initiating the IV in a hand vein for rapid access
f. Ensuring that the concentration is no greater than 1 mEq/10mL (mmol/10 mL) of
solution
Give this one a try later!
, c. Using an IV controller to deliver the drug
f. Ensuring that the concentration is no greater than 1 mEq/10mL (mmol/10
mL) of solution
Best practice technique for administering parenteral potassium
replacement is to ensure that the concentration is no greater than 1 mEq/10
mL of solution at a rate never to exceed 20 mEq/hr. A pump or controller
device must be used to deliver the drug to prevent rapid infusion and
complications of hyperkalemia, including cardiac arrest. IV potassium must
be infused via a large vein with a high volume of flow, avoiding the hand.
Potassium is not to be infused or pushed as a bolus to prevent cardiac.
Assessing the IV access for placement and an adequate blood return is
performed before administering potassium-containing solutions. It is not
necessary or good practice to keep the client NPO during parenteral
potassium administration.
Which action is the priority for the nurse to take to prevent harm for the alert 58-year-
old client who is admitted to the emergency department with wheezing, dyspnea,
angioedema, blood pressure of 70/52 mm Hg, and an irregular apical pulse of 122
beats/min?
a. Asking about exposure to possible allergens
b. Applying oxygen via a high-flow nonrebreather mask at 90% to 100%
c. Reassuring the client that appropriate interventions are being instituted
d. Starting an IV infusion of normal saline
Give this one a try later!
b. Applying oxygen via a high-flow nonrebreather mask at 90% to 100%
The immediate priority is to apply oxygen in order to provide adequate
oxygenation for the client who is in respiratory distress. Raising the lower
extremities, starting an IV infusion, and reassuring the client are not the first
priority for a client in respiratory distress.
(RA). Which client should the nurse see first?
a. Client who reports jaw pain when eating
b. Client with a red, hot, swollen right wrist
c. Client who has a puffy-looking area behind the knee
d. Client with a worse joint deformity since the last visit
Give this one a try later!
ANS: B
All of the options are possible manifestations of RA. However, the presence
of one joint that is much redder, hotter, or more swollen that the other
joints may indicate infection. The nurse needs to see this client first.
The nurse is caring for a client with osteoarthritis (OA) in the left knee. What factor
does the nurse suspect is the most likely cause of this client's OA?
,a. Trauma to the joint
b. Aging
c. Osteoporosis
d. Familial history
Give this one a try later!
a. Trauma to the joint
A student nurse asks the faculty to explain best practices when communicating with a
person from the lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ)
community. What answer by the faculty is most accurate?
a. Avoid embarrassing the client by asking questions.
b. Dont make assumptions about their health needs.
c. Most LGBTQ people do not want to share information.
d. No differences exist in communicating with this population.
Give this one a try later!
ANS: B
Many members of the LGBTQ community have faced discrimination from
health care providers and may be reluctant to seek health care. The nurse
should never make assumptions about the needs of members of this
population. Rather, respectful questions are appropriate. If approached
with sensitivity, the client with any health care need is more likely to answer
honestly.
Which assessments are most important for the nurse to perform to prevent harm on a
client with a sodium level of 118 mEq/L (mmol/L)? (Select all that apply.)
a. Testing skin turgor
,b. Asking about any abdominal pain
c. Assessing cognition
d. Checking deep tendon reflexes
e. Monitoring urine output
f. Checking for the presence of fever
Give this one a try later!
c. Assessing cognition
e. Monitoring urine output
The serum sodium is extremely low, which makes depolarization slower and
cell membranes less excitable. It also can cause cerebral edema to form,
leading to confusion and seizure activity. When sodium levels become very
low, coma and death may occur. Assessing cognition and checking deep
tendon reflexes are the most important assessment data to obtain.
Monitoring urine output needs to be done but is not the priority action in
this situation. Assessing skin turgor, presence of abdominal pain, and fever
are not an urgent assessment to prevent immediate harm.
Which actions are considered best practices for the nurse to use during the
administration of parenteral potassium to a client with a serum potassium level of 1.9
mEq/L (mmol/L) (Select all that apply.)
a. Keeping the client NPO during drug treatment
b. Pushing the drug as a bolus slowly over 5 minutes
c. Using an IV controller to deliver the drug
d. Checking IV access for blood return after the infusion
e. Initiating the IV in a hand vein for rapid access
f. Ensuring that the concentration is no greater than 1 mEq/10mL (mmol/10 mL) of
solution
Give this one a try later!
, c. Using an IV controller to deliver the drug
f. Ensuring that the concentration is no greater than 1 mEq/10mL (mmol/10
mL) of solution
Best practice technique for administering parenteral potassium
replacement is to ensure that the concentration is no greater than 1 mEq/10
mL of solution at a rate never to exceed 20 mEq/hr. A pump or controller
device must be used to deliver the drug to prevent rapid infusion and
complications of hyperkalemia, including cardiac arrest. IV potassium must
be infused via a large vein with a high volume of flow, avoiding the hand.
Potassium is not to be infused or pushed as a bolus to prevent cardiac.
Assessing the IV access for placement and an adequate blood return is
performed before administering potassium-containing solutions. It is not
necessary or good practice to keep the client NPO during parenteral
potassium administration.
Which action is the priority for the nurse to take to prevent harm for the alert 58-year-
old client who is admitted to the emergency department with wheezing, dyspnea,
angioedema, blood pressure of 70/52 mm Hg, and an irregular apical pulse of 122
beats/min?
a. Asking about exposure to possible allergens
b. Applying oxygen via a high-flow nonrebreather mask at 90% to 100%
c. Reassuring the client that appropriate interventions are being instituted
d. Starting an IV infusion of normal saline
Give this one a try later!
b. Applying oxygen via a high-flow nonrebreather mask at 90% to 100%
The immediate priority is to apply oxygen in order to provide adequate
oxygenation for the client who is in respiratory distress. Raising the lower
extremities, starting an IV infusion, and reassuring the client are not the first
priority for a client in respiratory distress.
