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?- Nurselytic

Question 1 of 5

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?

A. Assign a UAP to assist the client with a warm shower early in the morning. B. Provide the client with a warm blanket to reduce stiffness. C. Delay the procedure until the client is less stiff. D. Encourage the client to perform range-of-motion exercises.

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.

Question 2 of 5

The nurse is caring for a client with a history of atrial fibrillation who is prescribed warfarin (Coumadin). Which laboratory value should the nurse monitor closely?

A. Prothrombin time (PT) B. Hemoglobin level C. International Normalized Ratio (INR) D. Serum sodium level

Correct Answer: C

Rationale: 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 determine if the client's blood is clotting appropriately. While prothrombin time (PT) is related to warfarin therapy, the INR is a more precise measure. Hemoglobin level and serum sodium level are not directly related to monitoring warfarin therapy.

Question 3 of 5

The nurse is planning care for a client admitted with a diagnosis of pheochromocytoma. Which intervention has the highest priority for inclusion in this client's plan of care?

A. Record urine output every hour B. Monitor blood pressure frequently C. Evaluate neurological status D. Maintain seizure precautions

Correct Answer: B

Rationale: Monitoring blood pressure frequently is the highest priority intervention for a client diagnosed with pheochromocytoma. This rare tumor can lead to life-threatening hypertension due to catecholamine secretion. Evaluating neurological status and maintaining seizure precautions are important but are not the highest priority in this case. Recording urine output, though essential for overall assessment, is not the priority compared to monitoring blood pressure in a client with pheochromocytoma.

Question 4 of 5

A woman who takes pyridostigmine for myasthenia gravis (MG) arrives at the emergency department complaining of extreme muscle weakness. Her adult daughter tells the nurse that since yesterday her mother has been unable to smile. Which assessment finding warrants immediate intervention by the nurse?

A. Uncontrollable drooling. B. Inability to raise voice. C. Tingling of extremities. D. Eyelid drooping.

Correct Answer: A

Rationale: Uncontrollable drooling can be a sign of a myasthenic crisis, which requires immediate medical intervention to prevent respiratory failure. Drooling indicates difficulty in swallowing, which can lead to aspiration and respiratory compromise. Inability to raise voice (choice B) and tingling of extremities (choice C) are not typically associated with myasthenic crisis. Although eyelid drooping (choice D) is a common symptom of myasthenia gravis, it is not as urgent as uncontrollable drooling in indicating a potential crisis.

Question 5 of 5

An unlicensed assistive personnel (UAP) assigned to obtain client vital signs reports to the charge nurse that a client has a weak pulse with a rate of 44 beats/minute. What action should the charge nurse implement?

A. Instruct the UAP to count the client's apical pulse rate for sixty seconds. B. Determine if the UAP also measured the client's capillary refill time. C. Assign a practical nurse (LPN) to determine if an apical-radial pulse deficit is present. D. Notify the healthcare provider of the abnormal pulse rate and pulse volume.

Correct Answer: C

Rationale: The correct action for the charge nurse to implement in this situation is to assign a practical nurse (LPN) to determine if an apical-radial pulse deficit is present. This helps to confirm the accuracy of the reported weak pulse. In this scenario, it is crucial to involve a licensed nurse to further assess the situation and provide a more comprehensive evaluation. Inaccurate pulse readings can lead to inappropriate interventions or unnecessary alarm. Instructing the UAP to count the apical pulse may not address the accuracy issue. Checking capillary refill time is not directly related to confirming the weak pulse rate. Notifying the healthcare provider immediately may be premature without confirming the accuracy of the pulse reading first.

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Nurselytic

HESI RN