A male client with rheumatoid arthritis is scheduled for a procedure in the morning. The procedure cannot be completed because of early morning stiffness. Which intervention should the nurse implement?

Correct Answer: A

Rationale: A warm shower can help reduce morning stiffness, making the procedure more comfortable for the client. This intervention promotes comfort and mobility, addressing the immediate issue of stiffness. Providing a warm blanket (choice B) may offer some comfort but will not address the stiffness as effectively as a warm shower. Delaying the procedure (choice C) may inconvenience the client and not address the underlying stiffness issue. Encouraging range-of-motion exercises (choice D) is important for long-term management but may not provide immediate relief from the stiffness that is hindering the procedure.

Correct Answer: D

Rationale: The correct answer is to administer 50% dextrose IV push first. In hyperglycemic hyperosmolar syndrome, the main goal is to rapidly reduce blood glucose levels to prevent further complications. Administering dextrose intravenously can help reverse the effects of high blood glucose levels quickly. Administering intravenous fluids, monitoring urine output, and obtaining a blood glucose level are important interventions but are not the first priority in treating HHS. Administering 50% dextrose IV push takes precedence as it directly addresses the elevated blood glucose levels.

Correct Answer: C

Rationale: Subcutaneous emphysema requires immediate intervention in a client with a chest tube following a pneumothorax as it can indicate a pneumothorax recurrence or air leak. Oxygen saturation of 95% is within the normal range and does not require immediate intervention. Crepitus around the insertion site can be expected post-procedure and may not necessitate immediate action. Drainage of 50 ml per hour is a normal finding and does not raise immediate concerns.

Correct Answer: A

Rationale: The correct answer is A: 'Your baby is gaining weight right on schedule.' Tripling of birth weight by 6 months is a normal growth pattern in infants, indicating appropriate weight gain and development. Choice B is unrelated to the question as it focuses on the baby's diet rather than addressing the weight gain concern. Choice C is incorrect as tripling the birth weight is considered a healthy growth pattern, not below normal percentile. Choice D is irrelevant to the mother's question about the adequacy of weight gain.

Correct Answer: C

Rationale: The correct answer is C: Troponin level. Troponin levels should be closely monitored in a client with chest pain and a history of myocardial infarction to assess for ongoing myocardial injury. Troponin is a specific marker for myocardial damage. Monitoring white blood cell count (choice A) is not directly related to myocardial infarction. Serum creatinine (choice B) is more indicative of renal function rather than cardiac status. Hemoglobin level (choice D) is important but does not directly reflect ongoing myocardial injury.

Correct Answer: A

Rationale: The correct answer is A: Complaint of headaches and stiff neck. Headaches and stiff neck following a myelogram may indicate a cerebrospinal fluid (CSF) leak or other complications that require prompt medical attention. Reporting this finding immediately is crucial to prevent further complications. Choices B, C, and D are incorrect because while they may warrant monitoring and intervention, they are not as indicative of a potentially serious complication as the symptoms described in choice A.

Correct Answer: C

Rationale: The correct answer is C, International Normalized Ratio (INR). The INR should be closely monitored in a client prescribed warfarin (Coumadin) to assess the effectiveness and safety of anticoagulation therapy. Monitoring the INR helps ensure that the client is within the therapeutic range for anticoagulation, reducing the risk of bleeding or clotting complications. Prothrombin time (A) is used to calculate the INR and monitor the effectiveness of warfarin therapy. Hemoglobin level (B) is important but not the primary lab value to monitor when a client is on warfarin. Serum sodium level (D) is not directly related to monitoring warfarin therapy.

Correct Answer: C

Rationale: The correct task for the nurse to ask the unlicensed assistive personnel (UAP) to do in this situation is to "Get a blood pressure cuff." This is important because assessing the client's vital signs, including blood pressure, is crucial after a fall to ensure there are no underlying issues like hypotension. Choices A and B may be important tasks for the nurse to perform as part of the assessment and care of the client. However, in this scenario, the immediate concern should be to check the client's blood pressure. Choice D is not the most urgent task at this time, as assessing the client's condition takes precedence.

Correct Answer: A

Rationale: Observing the perineum is the priority action for the nurse in this situation. It allows the nurse to assess the stage of labor, determine the urgency of the situation, and provide immediate assistance if the baby is indeed about to be delivered. Preparing the delivery room and calling the obstetrician can follow once the nurse has assessed the situation. Administering pain relief may not be the immediate priority when the baby is coming.