A client is diagnosed with rheumatoid arthritis, an autoimmune disorder. When teaching the client and family about autoimmune disorders, the nurse should provide which information?

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Question 1 of 5

A client is diagnosed with rheumatoid arthritis, an autoimmune disorder. When teaching the client and family about autoimmune disorders, the nurse should provide which information?

Correct Answer: C

Rationale: Autoimmune disorders include connective tissue (collagen) disorders. Connective tissue disorders, such as rheumatoid arthritis, systemic lupus erythematosus, and scleroderma, are a type of autoimmune disorder. In these conditions, the body's immune system mistakenly attacks its own tissues, including the connective tissues. Therefore, it is important for the client and family to understand that connective tissue disorders fall under the category of autoimmune disorders. This knowledge can help them better understand the nature of the disease and how it affects the body.

Question 2 of 5

Aisa is to receive a liquid iron preparation. Which of the following directions would be appropriate for the nurse to teach Aisa's mother? a.Administer this at least an hour before meals

Correct Answer: C

Rationale: Avoid giving Aisa orange or other citric juices with the iron preparation. Citric juices, such as orange juice, can decrease the absorption of iron in the body. Therefore, it is important to avoid giving these juices when administering the liquid iron preparation to Aisa to ensure optimal absorption of the iron. It would be best to encourage the use of non-citric juices or water when administering the iron preparation to Aisa.

Question 3 of 5

The nurse is preparing to assist the physician with a bone marrow biopsy. Which of the ff. interventions is most important for the nurse to do before the procedure?

Correct Answer: B

Rationale: Before a bone marrow biopsy procedure, it is most important for the nurse to observe the patient for any signs of bleeding. This includes assessing the patient's coagulation status, looking for any bleeding disorders, and checking the patient's platelet levels. By monitoring for bleeding tendencies before the procedure, the nurse can ensure that the patient is in a stable condition to undergo the bone marrow biopsy safely. Additionally, post-procedure monitoring for bleeding is crucial to prevent complications such as hematoma formation. Explaining the procedure to the family, administering an analgesic, and draping the biopsy site are important steps, but ensuring the patient's safety by assessing for bleeding is the highest priority.

Question 4 of 5

Which of the ff. conditions places a patient at risk for respiratory complications following his splenectomy?

Correct Answer: C

Rationale: An incision near the diaphragm places a patient at risk for respiratory complications following a splenectomy. The diaphragm is the major muscle involved in the process of breathing, and if there is disruption or irritation near this area, it can lead to respiratory difficulties such as decreased lung expansion and pain on deep breathing. This can increase the risk of complications such as pneumonia, atelectasis, or respiratory distress. Therefore, special care should be taken to monitor and manage respiratory function in patients with incisions near the diaphragm post-splenectomy.

Question 5 of 5

A client who is receiving a blood transfusion begins to experience chills, shortness of breath, nausea, excessive perspiration, and a vague sense of uneasiness. What is the nurse's first best action?

Correct Answer: D

Rationale: The client is exhibiting signs of a transfusion reaction, most likely a hemolytic reaction. The first best action for the nurse to take in this situation is to immediately stop the blood transfusion to prevent further complications for the client. Once the infusion is stopped, the nurse can then proceed with assessing the client's vital signs, respiratory status, and other appropriate interventions. It is crucial to prioritize stopping the transfusion to ensure the client's safety and well-being.

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