Chapter 46

The nurse is teaching a client who is prescribed acetaminophen for control of osteoarthritic joint pain. What statement by the client indicates a need for further teaching? a. "I won't take more than 5000 mg of this drug each day." b. "I'll follow up to get my lab tests done to check my liver." c. "I'll check drugs that I take for acetaminophen in them." d. "I can use topical patches and creams to help relieve pain."

a - All of the choices are correct about acetaminophen except that the maximum daily dosage is 4000 mg. For older adults, 3000 mg are recommended due to slower drug metabolism by the liver.

A nurse is teaching a client newly diagnosed with osteoarthritis (OA) about drugs used to treat the disease. For which drug does the nurse plan health teaching? a. Acetaminophen b. Cyclobenzaprine hydrochloride c. Hyaluronate d. Ibuprofen

a - All of these drugs may be appropriate to treat OA. However, the first-line drug is acetaminophen. Cyclobenzaprine is a muscle relaxant given to treat muscle spasms. Hyaluronate is a synthetic joint fluid implant. Ibuprofen is a nonsteroidal anti-inflammatory drug.

A client who has rheumatoid arthritis is prescribed etanercept. What health teaching by the nurse about this drug is appropriate? a. Giving subcutaneous injections b. Having a chest x-ray once a year c. Taking the medication with food d. Using heat on the injection site

a - Etanercept is given as a subcutaneous injection twice a week. The nurse would teach the client how to self-administer the medication. The other options are not appropriate for etanercept.

The nurse is caring for a patient with leukemia who has severe fatigue. What action by the client best indicates that an important outcome to manage this problem has been met? a. Doing activities of daily living (ADLs) using rest periods b. Helping plan a daily activity schedule c. Requesting a sleeping pill at night d. Telling visitors to leave when fatigued

a - Fatigue is a common problem for clients with leukemia. This client is managing his or her own ADLs using rest periods, which indicates an understanding of fatigue and how to control it. Helping to plan an activity schedule is a lesser indicator. Requesting a sleeping pill does not help control fatigue during the day. Asking visitors to leave when tired is another lesser indicator. Managing ADLs using rest periods demonstrates the most comprehensive management strategy.

A nurse is caring for four clients with leukemia. After hand-off report, which client would the nurse assess first? a. Client who had two bloody diarrhea stools this morning. b. Client who has been premedicated for nausea prior to chemotherapy. c. Client with a respiratory rate change from 18 to 22 breaths/min. d. Client with an unchanged lesion to the lower right lateral malleolus.

a - The client who had two bloody diarrhea stools that morning may be hemorrhaging in the gastrointestinal (GI) tract and should be assessed first to monitor for or avoid the client from going into hypovolemic shock. The client with the slight change in respiratory rate may have an infection or worsening anemia and should be seen next. If the client's respiratory rate was greater than 28 to 30 breaths/min, the client may need the initial assessment. Marked tachypnea is an early sign of a deteriorating client condition. The other two clients are not a priority at this time.

A client is getting out of bed into the chair for the first time after an uncemented total hip arthroplasty. What action by the nurse is appropriate? a. Have adequate help to transfer the patient. b. Provide socks so the patient can slide easier. c. Tell the patient full weight bearing is allowed. d. Use a footstool to elevate the patient's leg.

a - The client with an uncemented hip will be on toe-touch only after surgery. The nurse would ensure there is adequate help to transfer the patient while preventing falls. Slippery socks may cause a fall. Elevating the leg is not going to assist with the client's transfer.

The nurse assesses a client after a total hip arthroplasty. The client's surgical leg is visibly shorter than the other one and the client reports extreme pain. While a co-worker calls the surgeon, what action by the nurse is appropriate? a. Assess neurovascular status in both legs. b. Elevate the surgical leg and apply ice. c. Prepare to administer pain medication. d. Try to place the surgical leg in abduction.

a - This client has signs and symptoms of hip dislocation, a potential complication of this surgery. Hip dislocation can cause neurovascular compromise. The nurse would assess neurovascular status while comparing both legs. The nurse would not try to move the extremity to elevate or abduct it. Pain medication may be administered if possible, but first the nurse would thoroughly assess the client.

A client has a platelet count of 9000/mm3 (9 109/L). The nurse finds the client confused and mumbling. What nursing action takes priority at this time? a. Call the Rapid Response Team. b. Take a set of vital signs. c. Institute bleeding precautions. d. Place the client on bedrest.

a - With a platelet count this low, the client is at high risk of spontaneous bleeding. The most disastrous complication would be intracranial bleeding. The nurse needs to call the Rapid Response Team as this client has manifestations of a sudden neurologic change. Bleeding precautions will not address the immediate situation. Placing the client on bedrest is important, but the critical action is to call for immediate medical attention.

The nurse is assessing a client with chronic leukemia. Which laboratory test result(s) is (are) expected for this client? (Select all that apply.) a. Decreased hematocrit b. Abnormal white blood cell count c. Low platelet count d. Decreased hemoglobin e. Increased albumin

a, b, c, d - Chronic leukemia affects all types of blood cells causing a decrease is red blood cells (RBCs) and platelets. When the number of RBCs decreases, the client's hemoglobin and hematocrit also decrease. White blood cell counts are also abnormal depending on disease progression and management.

The nurse is caring for a client being treated for Hodgkin lymphoma. For which side effect(s) of treatment will the nurse assess? (Select all that apply.) a. Severe nausea and vomiting b. Low platelet count c. Skin irritation at radiation site d. Low red blood cell count e. High white blood cell count

a, b, c, d - Drug and radiation therapy for Hodgkin lymphoma cause many side and adverse effects, including all of the choices except for a high white blood cell (WBC) count. Instead, most clients experience a low WBC count making them very susceptible to infections.

A client who had a recent total knee arthroplasty will be using a continuous passive motion (CPM) machine after discharge at home. What health teaching about the CPM machine will the nurse include? (Select all that apply.) a. "Keep the machine padded well to prevent skin breakdown." b. "Ensure that your leg is placed properly on the machine." c. "Use the machine as prescribed but not at mealtime." d. "When the machine is not being used, do not store it on the floor." e. "Check that the cycle and range of motion is kept at the level prescribed."

a, b, c, d, e - Although not used as often today, some clients are prescribed to use the CPM machine to increase range of motion in the surgical knee. All of these teaching points are important for any client who uses a CPM machine.

The nurse is teaching assistive personnel about postoperative care for an older adult who had a posterolateral total hip arthroplasty. What teaching will the nurse include? (Select all that apply.) a. "Move the client slowly to prevent dizziness and a possible fall." b. "Encourage the client to deep breathe and cough at least every 2 hours." c. "Help the client use the incentive spirometer at least every 2 hours." d. "Keep the abduction pillow in place at all times while the client is in bed." e. "Let me know if the client has an elevated temperature or pulse." f. "Keep in mind that the client may be a little confused after surgery." g. "Please let me know if you see any reddened or open skin areas during bathing."

a, b, c, d, e, f - Older adults are at risk for complications of decreased mobility after surgery, including atelectasis, pneumonia, pressure injuries, and orthostatic hypotension. Therefore these precautions are to help keep the client safe and avoid complications that could be life threatening.

The nurse is assessing a client with long-term rheumatoid arthritis (RA) who has been taking prednisone for 10 years. For which complications of chronic drug therapy would the nurse assess? (Select all that apply.) a. Osteoporosis b. Diabetes mellitus c. Glaucoma d. Hypertension e. Hypokalemia f. Decreased immunity

a, b, c, d, e, f - Prednisone is a corticosteroid that is sometimes used for autoimmune disorders like RA when other drugs are not effective or cannot be tolerated. However, it can cause many complications when used long-term, including all of the health problems listed in the choices.

A client has rheumatoid arthritis (RA) and the nurse is conducting a home assessment. What options can the nurse suggest for the client to maintain independence in activities of daily living (ADLs)? (Select all that apply.) a. Grab bars to reach high items b. Long-handled bath scrub brush c. Soft rocker-recliner chair d. Toothbrush with built-up handle e. Wheelchair cushion for comfort

a, b, d - Grab bars, long-handled bath brushes, and toothbrushes with built-up handles all provide modifications for daily activities, making it easier for the client with RA to complete ADLs independently. The rocker-recliner and wheelchair cushion are comfort measures but do not help increase independence. Most clients who have RA are not wheelchair-bound.

A nurse is visiting a client discharged home after a total hip arthroplasty. What safety precautions would the nurse recommend to the client and family? (Select all that apply.) a. Buy and install an elevated toilet seat. b. Install grab bars in the shower and by the toilet. c. Step into the bathtub with the affected leg first. d. Remove all throw rugs throughout the house. e. Use a shower chair while taking a shower.

a, b, d, e - Buying and installing an elevated toilet seat, installing grab bars, removing throw rugs, and using a shower chair will all promote safety for this client. The client is still on partial weight bearing, so he or she cannot step into the bathtub leading with the operative side.

A client asks the nurse about what medications may be included for nonopioid multimodal analgesia following a total knee arthroplasty. What medications may be given to the client? (Select all that apply.) a. Gabapentin b. Ketorolac c. Hydrocodone d. Ketamine e. Morphine f. Bupivacaine

a, b, d, f - All of the choices are appropriate to use for nonopioid multimodal analgesia except for the two opioid drugs—hydrocodone and morphine. The nonopioid medications are used to decrease inflammation and pain.

The nurse is assessing a client for signs and symptoms of systemic lupus erythematosus (SLE). Which of the following would be consistent with this disorder? (Select all that apply.) a. Discoid rash on skin exposed to sunlight b. Urinalysis positive for casts and protein c. Painful, deformed small joints d. Pain on inspiration e. Thrombocytosis f. Serum positive for antinuclear antibodies (ANA)

a, b, d, f - Signs and symptoms of SLE include (but are not limited to) a discoid rash on skin exposed to the sun, urinalysis with casts and protein, pleurisy as manifested by pain on inspiration, and positive ANA titers in the blood. Nonerosive arthritis in peripheral joints can occur but does not lead to deformity. Thrombocytopenia is another sign.

The nurse is caring for an older client who had a total knee arthroplasty. Prior to surgery, the client lived alone independently. With which interprofessional health care team members will the nurse collaborate to ensure positive client outcomes? (Select all that apply.) a. Case manager b. Mental health counselor c. Physical therapist d. Occupational therapist e. Speech-language pathologist f. Clergy/Spiritual leader

a, c - The client was independent and living alone prior to surgery but will likely need help for a short time at home. However, if the client was ADL independent, he or she will not need referral to an occupational therapist. Therefore, a case manager can assess the living situation and identify any special needs to be addressed. The physical therapist will help the client learn to ambulate independently with a walker. There is no indication that the client needs referral for mental, spiritual, or speech-language services.

A nurse is planning postoperative care for a client following a total hip arthroplasty. What nursing interventions would help prevent venous thromboembolism for this client? (Select all that apply.) a. Early ambulation b. Fluid restriction c. Quadriceps-setting exercises d. Compression stockings/devices e. Anticoagulant drug therapy

a, c, d, e - Early ambulation, leg exercises, and compression stockings/devices promote venous return and peripheral circulation which helps prevent deep vein thrombi. Anticoagulants such as subcutaneous low-molecular-weight heparin (LMWH) or factor Xa inhibitors are used for all clients who have a total lower extremity joint arthroplasty. The nurse would encourage fluids to expand blood volume and promote circulation; fluids would not be restricted.

Which risk factor(s) places a client at risk for leukemia? (Select all that apply.) a. Chemical exposure b. Genetically modified foods c. Ionizing radiation exposure d. Vaccinations e. Viral infections

a, c, e - Chemical and ionizing radiation exposure and viral infections are known risk factors for developing leukemia. Eating genetically modified food and receiving vaccinations are not known risk factors.

A client is being administered the first dose of belimumab for a systemic lupus erythematosus flare. What actions by the nurse are most appropriate? (Select all that apply.) a. Observe the client for at least 2 hours afterward. b. Instruct the client about the monthly infusion schedule. c. Inform the client not to drive or sign legal papers for 24 hours. d. Ensure emergency equipment is working and nearby. e. Make a follow-up appointment for a lipid panel in 2 months. f. Instruct the client to hold other medications for 72 hours.

a, d - This drug is a monoclonal antibody to tumor necrosis factor. The first dose would be administered in a place where severe allergic reactions and/or anaphylaxis can be managed. This includes having emergency equipment nearby. The client would be observed for at least 2 hours after this first dose. This drug does not cause drowsiness, so there would be no restrictions on driving or signing legal documents. Elevated lipids are not associated with this drug. This drug is used in combination with other therapies, especially during a flare.

The family of a neutropenic client reports that the client "is not acting right." What action by the nurse is the priority? a. Ask the client about pain. b. Assess the client for infection. c. Take a set of vital signs. d. Review today's laboratory results.

b - Neutropenic clients often do not have classic manifestations of infection, but infection is the most common cause of death in neutropenic clients. The nurse would definitely assess for infection. The nurse would assess for pain but this is not the priority.

A nurse assesses a group of clients who have rheumatoid arthritis (RA). Which client would 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

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 or an exacerbation of the RA disease process. The nurse needs to see this client first.

The nurse assesses a client with diabetes and osteoarthritis (OA) during a checkup. The nurse notes the client's blood glucose readings have been elevated. What question by the nurse is most appropriate? a. "Are you following the prescribed diabetic diet?" b. "Have you been taking glucosamine supplements?" c. "How much exercise do you really get each week?" d. "You're still taking your diabetic medication, right?"

b - All of the topics are appropriate for a client whose blood glucose readings have been higher than usual. However, since this client also has OA, and glucosamine can increase blood glucose levels, the nurse would ask about its use. The other questions all have an element of nontherapeutic communication in them. Asking how much exercise the client "really" gets is or if the diet is being followed is accusatory. Asking if the client takes his or her medications "right?" is patronizing.

A client has been newly diagnosed with systemic lupus erythematosus and is reviewing self-care measures with the nurse. Which statement by the client indicates a need to review the material? a. "I will avoid direct sunlight as much as possible." b. "Baby powder is good for the constant sweating." c. "Grouping errands will help prevent fatigue." d. "Rest time will have to become a priority."

b - Constant sweating is not a sign of SLE and powders are drying so they should not be used, at least not in excess. The client is correct in stating he/she should avoid direct sunlight, that grouping errands can prevent or reduce fatigue, and that rest will have to become a priority.

A client with rheumatoid arthritis (RA) has an acutely swollen, red, and painful joint. What nonpharmacologic intervention does the nurse recommend? a. Heating pad b. Ice packs c. Splint d.Paraffin

b - Ice is best for acute inflammation. Heat often helps with joint stiffness. Splinting helps preserve joint function. A paraffin dip is used to provide warmth to the joint which is more appropriate for chronic pain and stiffness.

A client asks the nurse about having a total knee arthroplasty to relieve joint pain. Which factor would place the client at the highest risk for impaired postoperative healing? a. Controlled hypertension b. Obesity c. Osteoarthritis d. Mild osteopenia

b - Obesity places a client at high risk for many postoperative complications including slower wound and bone healing. The other factors usually do not affect healing after surgery.

The nurse is assessing a client who has probable lymphoma. What is the most common early assessment finding for clients with this disorder? a. Weight gain b. Enlarged painless lymph node(s) c. Fever at night d. Nausea and vomiting

b - The first change that is noted for clients with probable lymphoma is one or more enlarged lymph nodes. The other findings are either not common in clients with lymphoma or later findings.

The nurse is teaching a client with mild rheumatoid arthritis (RA) about how to protect synovial joints. Which health teaching will the nurse include? (Select all that apply.) a. "Use small joints rather than larger ones during tasks." b. "Use both hands instead of one with holding objects." c. "When getting out of bed or a chair, use the palms of your hands." d. "Bend your knees instead of your waist and keep your back straight." e. "Do not use multiple pillows under your head to prevent neck flexion." f. "Use a device or rubber grip to open jars or bottle tops." g. "Use long-handled devices such as a hairbrush with an extended handle."

b, c ,d, e, f, g - All of these options are part of health teaching for joint protection except that large joints should be used instead of smaller ones.

The nurse assesses a client with long-term rheumatoid arthritis (RA) for late signs and symptoms. Which assessment findings will the nurse document as late signs and symptoms of RA? (Select all that apply.) a. Anorexia b. Felty syndrome c. Joint deformity d. Low-grade fever e. Weight loss

b, c, e - Late signs and symptoms of RA include Felty syndrome, joint deformity, weight loss, organ involvement, osteoporosis, extreme fatigue, and anemia, among others. Anorexia and low-grade fever are both seen early in the course of the disease.

A nurse caring for clients with systemic lupus erythematosus (SLE) plans care understanding the most common causes of death for these clients is which of the following? (Select all that apply.) a. Infection b. Cardiovascular impairment c. Vasculitis d. Chronic kidney disease e. Liver failure f. Blood dyscrasias

b, d - Any and all organs and tissues may be affected in SLE but the most common causes of death in clients with SLE include cardiovascular impairment and chronic kidney disease.

The nurse is teaching a client who is planning to have a total hip arthroplasty. What statement by the client indicates a need for further teaching? a. "I will get an IV antibiotic right before surgery to prevent infection." b. "I may request a regional nerve block as part of the surgical anesthesia." c. "I will receive IV heparin before surgery to decrease the risk of clots."d. "I will receive tranexamic acid to help reduce blood loss during surgery."

c - All of the choices are correct except that IV heparin is not given before or after surgery. A different anticoagulant is given after surgery to prevent postoperative venous thromboembolism, such as deep vein thrombosis and pulmonary embolus.

A client is prescribed celecoxib for joint pain. What statement by the client indicates a need for further teaching? a. "I'll report any signs of bleeding or bruising to my primary health care provider." b. "I'll take this drug only as prescribed by my primary health care provider." c. "I'll be sure to take this drug three times a day only on an empty stomach." d. "I'll monitor the amount of urine that I excrete every day and report any changes."

c - All of the choices are correct for this NSAID except that celecoxib can cause GI distress unless taken with meals or food. The drug should not be taken on an empty stomach and is rarely taken more than twice a day.

The primary health care provider prescribes methotrexate (MTX) for a client with a new diagnosis of rheumatoid arthritis. The nurse provides health teaching about the drug. What statement by the nurse is appropriate to include about methotrexate? a. "It will take at least 1 to 2 weeks for the drug to help relieve your symptoms." b. "The drug is very expensive but there are pharmacy plans to help pay for it." c. "The drug can increase your risk for infection, so you should avoid crowds." d. "It's OK for you to drink about 2 to 3 glasses of wine each week while taking the drug."

c - MTX takes up to 4 to 6 weeks to begin to help relieve RA symptoms and is very inexpensive. Clients should avoid alcohol due to the potential for liver toxicity. MTX suppresses the immune system which makes clients susceptible to infection. The nurse teaches clients to avoid crowds and anyone with a known infection.

A client has long-term rheumatoid arthritis that especially affects the hands. The client wants to finish quilting a baby blanket before the birth of her grandchild. What response by the nurse is appropriate? a. "Let's ask your provider about increasing your pain pills." b. "Hold ice bags against your hands before quilting." c. "Try a paraffin wax dip 20 minutes before you quilt." d. "You need to stop quilting before it destroys your fingers."

c - Paraffin wax dips are beneficial for decreasing pain in arthritic hands and lead to increased mobility. Increasing pain pills may not help with movement. Ice has limited use unless the client has a "hot" or exacerbated joint. The client wants to finish the project, so the nurse would not negate its importance by telling the client it is destroying her joints.

A client has thrombocytopenia. What statement indicates that the client understands self-management of this condition? a. "I brush and use dental floss every day." b. "I chew hard candy for my dry mouth." c. "I usually put ice on bumps or bruises." d. "Nonslip socks are best when I walk."

c - The client should be taught to apply ice to areas of minor trauma. Flossing is not recommended. Hard foods should be avoided. The client should wear well-fitting shoes when ambulating.

The nurse is caring for a client who has severe osteoarthritis. What primary joint problems will the nurse expect the client to report? a. Crepitus b. Effusions c. Pain d. Deformities

c - The primary assessment finding typically reported by clients who have osteoarthritis is joint pain, although crepitus, effusions (fluid), and mild deformities may occur.

After a total knee arthroplasty, a client is on the postoperative nursing unit with a continuous femoral nerve blockade. On assessment, the nurse notes the skin of both legs is pale pink, warm, and dry, but the client is unable to dorsiflex or plantarflex the surgical foot. What action would the nurse take next? a. Document the findings and monitor as prescribed. b. Increase the frequency of monitoring the client. c. Notify the surgeon or anesthesia provider immediately. d. Palpate the client's bladder or perform a bladder scan.

c - With the femoral nerve block, the client would still be able to dorsiflex and plantarflex the affected surgical foot. Since this client has an abnormal finding, the nurse would notify either the surgeon or the anesthesia provider immediately. Documentation is the last priority. Increasing the frequency of assessment may be appropriate, but first the nurse must notify the appropriate provider. Palpating the bladder is not related.

The nurse interviews an older client with moderate osteoarthritis and her husband. What psychosocial assessment question would the nurse include? a. "Do you feel like hurting yourself or others?" b. "Are you planning to retire due to your disease?" c. "Do you ask your husband for assistance?" d. "Do you experience discomfort during sex?"

d - Although some clients can become depressed and anxious as a result of having OA, suicidal ideation is not common. The nurse should not assume that an older adult will want to retire or that the client will need help from her husband. Many clients avoid sexual intercourse because of joint pain and stiffness.

An assistive personnel is caring for a client with leukemia and asks why the client is still at risk for infection when the white blood cell count (WBC) is high. What response by the nurse is correct? a. "If the WBCs are high, there already is an infection present." b. "The client is in a blast crisis and has too many WBCs." c. "There must be a mistake; the WBCs should be very low." d. "Those WBCs are abnormal and don't provide protection."

d - In leukemia, the WBCs are abnormal and do not provide protection to the client against infection. The other statements are not accurate.

The nurse assesses a client with rheumatoid arthritis (RA) and Sjögren syndrome. What assessment would be most important for this client? a. Abdominal assessment b. Oxygen saturation c. Breath sounds d. Visual acuity

d - Sjögren syndrome may be seen in clients with RA and manifests with dryness of the eyes, mouth, and vagina in females. Visual disturbances can occur. The other assessments are not related to Sjögren syndrome.

Which statement by a client with leukemia indicates a need for further teaching by the nurse? a. "I will use a soft-bristled toothbrush and avoid flossing." b. "I will not take aspirin or any aspirin product." c. "I will use an electric shaver instead of my manual one." d. "I will take a daily laxative to prevent constipation."

d - The client experiencing leukemia needs to prevent injury to prevent bleeding, including avoiding hard-bristled toothbrushes, floss, aspirin, and straight or manual safety razors. However, although constipation can cause hemorrhoids or rectal bleeding, laxatives can cause fluid and electrolyte imbalances and abdominal cramping. Stool softeners would be a better option to allow the passage of soft stool.

A nurse is teaching the client with systemic lupus erythematosus about prednisone. What information is the priority? a. Might make the client feel jittery or nervous. b. Can cause sodium and fluid retention. c. Long-term effects include fat redistribution. d. Never stop prednisone abruptly.

d - The nurse teaches the client to avoid stopping the drug abruptly as the priority because this can lead to a life-threatening adrenal crisis. Short-term side effects do include jitteriness or nervousness, sodium and water retention. One long-term side effect is fat redistribution resulting in "moon face" and "buffalo hump.

A client is scheduled to have a total hip arthroplasty. What preoperative teaching by the nurse is most important? a. Teach the need to discontinue all medications for 5 days before surgery. b. Teach the patient about foods high in protein, Vitamin C, and iron. c. Explain to the client the possible need for blood transfusions postoperatively. d. Remind the client to have all dental procedures completed at least 2 weeks prior to surgery.

d - The nurse would include teaching about dental procedures to avoid infection after new joint has been inserted. Planned procedures would be completed at least 2 weeks before surgery and the client will need to tell any future primary health care providers about having a total joint arthroplasty. Only home medications prescribed that increase the risk for bleeding or clotting need to be discontinued 5 to 10 days before surgery. Clients need to be aware that any postoperative anemia may need to be treated with a blood transfusion, but it is not the most important. Diets high in protein, Vitamin C, and iron help with tissue repair, but are not the most important.