The nurse is caring for 4 clients. What client should the nurse see first?

Correct Answer: C

Rationale: The correct answer is the client on Methotrexate with a fever. Fever in a client on Methotrexate, an immunosuppressant, could indicate a serious infection or adverse drug reaction requiring immediate attention to prevent complications. The other choices do not present immediate life-threatening concerns. A client with lupus asking for dinner can wait, a client with chronic rheumatic pain may need pain management but is not the priority over a fever in a client on Methotrexate, and a client with children visiting does not pose an urgent medical issue.

Correct Answer: A

Rationale: The correct answer is A) Shearing or friction. When a client sustains an injury to the heel while being moved in bed, shearing or friction forces are the most likely cause. Shearing occurs when tissues move in opposite directions, causing layers of tissue to stretch and tear. Friction can also contribute to skin breakdown and injury when there is excessive rubbing or sliding of the skin against a surface. Option B) Twisting and bending, is incorrect in this context because these forces are more likely to cause musculoskeletal injuries rather than a heel injury related to movement in bed. Option C) Pressure or gravity, while important factors in healthcare and patient care, are not the primary forces at play when discussing an injury to the heel during movement. Pressure ulcers may result from sustained pressure over bony prominences, but in this scenario, the injury is more likely due to shearing or friction forces. Option D) Chemical or pressure are also not relevant in this context of a heel injury during movement in bed. Educationally, understanding the mechanisms of injury related to patient movement is crucial for healthcare providers to prevent harm and ensure patient safety. Proper techniques, equipment use, and communication between healthcare team members can help mitigate risks associated with patient transfers and positioning. This knowledge is vital in promoting safe and effective care for patients in various healthcare settings.

Correct Answer: C

Rationale: In this scenario, the priority intervention for the client experiencing increased pain during a dressing change is option C) Teach the client about nonpharmacological pain control methods. This is the correct choice because the client's pain management needs to be addressed effectively to ensure their comfort and well-being during the dressing change procedure. Option A) Offer the client protein with meals to promote healing is incorrect as it does not directly address the immediate issue of managing the client's pain during the dressing change. Option B) Remove the old dressing with clean gloves is also incorrect as it overlooks the need to address the client's pain management before proceeding with the dressing change. Option D) Check medication administration record (MAR) for as needed orders (PRN) is not the priority in this situation as the client's pain needs to be managed promptly during the dressing change, and nonpharmacological methods should be considered first before resorting to medications. Educationally, it is important to understand that assessing and managing a client's pain is a crucial aspect of nursing care. By teaching the client about nonpharmacological pain control methods, nurses empower clients to participate in their own care and enhance their overall comfort and well-being. Effective pain management not only improves the client's experience but also promotes better outcomes and healing.

Correct Answer: D

Rationale: In this scenario, the nurse's priority action should be to culture the wound (Option D). Culturing the wound is essential to identify the specific bacteria causing the infection, which will guide appropriate antibiotic therapy. By obtaining a wound culture, the nurse can ensure targeted treatment for the infection, leading to better outcomes for the client. Option A, inserting the wound and assessing the drainage, is not the priority action in this case. While wound assessment is important, obtaining a culture to identify the infectious organism takes precedence. Option B, applying topical ointment to the wound, may provide some symptomatic relief but does not address the underlying cause of the infection. Antibiotic therapy based on culture results is necessary for effective treatment. Option C, calling the provider to initiate antibiotics, is premature without knowing the specific bacteria causing the infection. Starting antibiotics without a culture may lead to inappropriate treatment and potential antibiotic resistance. In an educational context, understanding the rationale behind prioritizing actions in wound care is crucial for nursing practice. Emphasizing the importance of evidence-based interventions, such as wound cultures, reinforces the significance of thorough assessment and individualized treatment plans in providing quality patient care.

Correct Answer: A

Rationale: In clients with lupus, a classic symptom that is commonly assessed is the butterfly rash, which appears on the face resembling the shape of a butterfly across the cheeks and bridge of the nose. This rash is a hallmark sign of lupus and is often one of the first visible symptoms to appear. Option B, Chvostek's sign, is actually associated with hypocalcemia and is manifested as facial muscle spasms when the facial nerve is tapped. Option C, Ovid's sign, is a distractor as it is not a recognized medical sign or symptom in relation to lupus or any other condition. Option D, Heberden's nodes, are bony swellings that occur at the distal interphalangeal joints in osteoarthritis, which is not typically associated with lupus. Understanding these distinctions is crucial for healthcare providers to accurately assess and diagnose lupus in patients. Recognizing the key symptoms of lupus, such as the butterfly rash, aids in prompt intervention and management of the condition, ultimately improving patient outcomes.