Detailed Answer Ke
ty ty
yMedical Surgical, A
ty ty ty
+
1. A nurse is reviewing the cause of gout with a group of nurses. Which of the following statements should the nurse
make?
A. "Uric acid levels drop and calcium forms precipitate."
Rationale: With gout, clients have hyperuricemia, rather than a reduction in uric acid.
B. "Tophi form in the kidneys and they impair the excretion of uric acid."
Rationale: Tophi, or deposits in tissues near a joint, develop in chronic, late-stage gout. They are not part of
the primary disease process.
C. "The intra-articular deposition of urate crystals causes inflammation."
Rationale: Gout, or gouty arthritis, develops when urate crystals deposit in joints and tissues and cause
inflammation and pain.
D. "Articular cartilage thins, leading to splitting and fragmentation."
Rationale: Gout does not thin and fragment cartilage.
2. Atynursetyistyteachingtyatygrouptyoftyclientstyabouttyosteoarthritis.tyWhichtyoftythetyfollowingtyrecommendationstyshouldt
ythetn
y ursetyincludetyintythetyteaching?
A. UsetyEchinaceatytotymanagetyjointtypain.
Rationale:tyThet y nurset y mayt y includet y thet y uset y oft y complementaryt y andt y alternativet y therapiest y int y thet y teaching.
However,tyEchinaceatyistyusedtyfortythetytreatmenttyoftythetycommontycold,tynottyosteoarthritis.tyAlterna
tivettyherapiestythattyaretyusedtyfortyosteoarthritistyincludetyglucosamine,tychondroitin,tyandtytopicaltycap
saicin.
B. Applytyicetytotythetyjointtybeforetyexercising.
Rationale:tyThet y nurset y shouldt y recommendt y thatt y thet y clientst y begint y exercisingt y immediatelyt y followi
ngt y theta
y pplicationtyoftyheat.tyThistyreducestypaintyandtyimprovestymobility,tyallowingtyfortyincr
easedtyrange-of-
motiontyduringtyexercises.tyColdtyapplicationtymaytybetyappliedtyfollowingtyexercisetytotd y ecrea
setydiscomforttyandtyinflammation.
C. Maintaintyatyrecommendedtybodytyweight.
Rationale:tyObesitytyistyatyrisktyfactortyfortythetydevelopmenttyoftyosteoarthritis.tyMaintenancetyoftyantyidealtyweig
httyisto
y netywaytyatyclienttycantypreventtyaddedtyweartyandtyteartyontyjointstyandtypromotetyoveralltyjointty
health.
D. Reducetythetyamounttyoftypurinetyintythetydiet.
Rationale:tyThetynursetyshouldtyrecognizetythattylimitingtypurinetyintythetydiet,tywhichtyistyoftentyfoundtyintyorgantyme
ats,tiystyrecommendedtyfortyclientstywhotyhavetygout.
3. Atynursetyistycaringtyfortyatyclienttywhotyhastyhadtyatymyocardialtyinfarction.tyUpontyhistyfirsttyvisittytotycardiactyrehabilitatio
n,tyhettyellstythetynursetythattyhetydoesn'ttyunderstandtywhytyhetyneedstytotybetytheretybecausetytheretyistynothingtymoretytoty
do,tyastythe
Pagety1
,Detailed Answer Ke
ty ty
yMedical Surgical, A
ty ty ty
+
damagetyistydone.tyWhichtyoftythetyfollowingtyistythetycorrecttynursingtyresponse?
A. "Cardiactyrehabilitationtycannottyundotythetydamagetytotyyourtyhearttybuttyittycantyhelptyyoutygettybacktytotyyourtyprev
ioustlyeveltyoftyactivitytysafely."
Rationale:tyWithtythistyresponse,tythetynursetyusestythetytherapeutictycommunicationtytechniquetyoftypresentingrty
ealitytybytyindicatingtyhertyperceptiontyoftythetysituationtyfortythetyclient.
B. "It’stynottyunusualtytotyfeeltythattywaytyattyfirst,tybuttyoncetyyoutylearntythetyroutine,tyyou’lltyenjoytyit."
Rationale:tyWitht y thist y response,t y thet y nurset y illustratest y thet y nontherapeutict y communicationt y techniquet y oft y giv
ingtry eassurance,tythustydiscouragingtythetyclienttyfromtyfurthertycommunication.
C. "Exercisetyistygoodtyfortyyoutyandtygoodtyfortyyourtyheart."
Rationale:tyWitht y thist y response,t y thet y nurset y illustratest y thet y nontherapeutict y communicationt y techniquest y ofd
ty is
agreeingtyandtygivingtyadvice.
D. "Yourtydoctortyistythetyexperttyhere,tyandtyI’mtysuretyhetywouldtyonlytyrecommendtywhattyistybesttyfortyyou."
Rationale:tyWitht y thist y response,t y thet y nurset y illustratest y thet y nontherapeutict y communicationt y techniquet y ofd
ty ef
ending.
4. Atynursetyistycaringtyfortyatyclienttywhotyhastyhearttyfailuretyandtyatypotassiumtyleveltyofty2.4tymEq/L.tyThetynursetyshouldtyid
entifytywhichtyoftythetyfollowingtymedicationstyastythetycausetyoftythetyclient’stylowtypotassiumtylevel?
A. Furosemide
Rationale:tyFurosemidetyistyatyloopty(high-
ceiling)tydiuretictythattyinhibitstythetyreabsorptiontyoftysodiumtyandtychloridea
ty ndtyresultstyintydiuresis,tywh
ichtydecreasestypotassiumtythroughtyexcretiontyintythetydistaltynephrons.
Hypokalemiatyistyantyadversetyeffecttyoftyfurosemide.
B. Nitroglycerin
Rationale:tyAtypotassiumtyleveltyofty2.4tymEq/Ltyistynottyantyadversetyeffecttyoftynitroglycerin.tyNitroglycerintyistyav
ty asod
ilatortymedicationtytotytreattyangina.
C. Metoprolol
Rationale:tyAtypotassiumtyleveltyofty2.4tymEq/Ltyistynottyantyadversetyeffecttyoftymetoprolol.tyMetoprololty
istyatb
y eta-
blockertythattyslowstythetyhearttyratetyandtyimprovestycontractilitytyoftythetyhearttymuscle.
D. Spironolactone
Rationale:tySpironolactonetyistyatypotassium-
sparingtydiuretictymedication;tytherefore,tyhyperkalemiatyistyana
ty dversetyeffecttyoftythistymedication.
5. Atynursetyistycaringtyfortyatyclienttywhotyistypostoperativetyfollowingtyantyopentyreductiontyinternaltyfixationty(ORIF)tyoftyatyfem
urtyfracture.tyWhichtyoftythetyfollowingtyparameterstyshouldtythetynursetyincludetyintythetyevaluationtyoftythetyneurovasculartyst
atustyofttyhetyclient'styaffectedtyextremity?ty(Selecttyalltythattyapply.)
Pagety2
,Detailed Answer Ke
ty ty
yMedical Surgical, A
ty ty ty
+
A. Color
B. Temperature
C. Ecchymosis
D. Skintyintegrity
E. Sensation
Rationale:tyColortyistycorrect.tyClientstywhotyhavetysustainedtytraumatytotyantyextremity,tysuchtyastyatyfracture,tyarety
attyincreasedtyrisktyfortyneurovasculartycompromise.tyThetynursetyshouldtychecktythetycolortyoftythetyclie
nt'styaffectedtyextremitytyastyparttyoftythistyassessment.tyThetynursetyshouldtyidentifytypallortyortycyanosi
styoftythete
y xtremitytyastyantyindicationtyoftyperipheraltyneurovasculartydysfunctiontyandtyshouldtynotifytyt
hetyprovider.Temperaturetyistycorrect.tyClientstywhotyhavetysustainedtytraumatytotyantyextremity,tysucht
yastyatyfracture,tyaretyattyincreasedtyrisktyfortyneurovasculartycompromise.tyThetynursetyshouldtymonitort
ythetytemperaturetyoftythetyextremitytyastyatyparttyoftythistyassessmenttyandtyidentifytyskintythattyistycooltyo
rtycoldtytotythetytouchtyastyhavingtydecreasedtyperfusiontytotythetytissuestyoftythetyextremity,tywhichtyistyan
tyindicationtyoftpy eripheraltyneurovasculartydysfunction.tyThetynursetyshouldtyreporttyskintythattyistycooltyt
otythetytouchtytotythetyprovider.Ecchymosistyistyincorrect.tyEcchymosis,tyortybruising,tyistyantyexpectedtyf
indingtywithtylegtyinjuriestyandtyistynottyatycomponenttyoftyatyneurovasculartycheck.Skintyintegritytyistyinc
orrect.tyWhiletythetynursetyshouldtyassesstythetyincisiontyoftyatyclienttywhotyistypostoperativetyfollowingty
antyopentyreductiontyandtyinternaltyfixationtyoftythetyfemur,tyittyistynottyatycomponenttyoftyatyneurovascula
rtycheck.Sensationtyistycorrect.tyClientstywhotyhavetysustainedtytraumatytotyantyextremity,tysuchtyastyatyf
racture,tyaretyattyincreasedtyrisktyfortyneurovasculartycompromise.tyThetynursetyshouldtyassesstythetycli
ent'styextremitytyfortynumbnessto y rtytingling.tyThetynursetyshouldtyrecognizetydiminishedtypaintyortypares
thesiatyastyantyindicationtyoftydamagetytotythetynervestyortyperipheraltyneurovasculartydysfunctiontyandty
shouldtyreporttyittytotythetyprovider.
6. Atynursetyistymonitoringtyatyclienttyfollowingtyatythoracentesis.tyThetynursetyshouldtyidentifytywhichtyoftythetyfollo
wingtm
y anifestationstyastyatycomplicationtyandtycontacttythetyprovidertyimmediately?
A. Serosanguineoustydrainagetyfromtythetypuncturetysite
Rationale:tyAtysmalltyamounttyoftyserosanguineoustydrainagetyattythetypuncturetysitetyistyexpectedtyaftertyatty horacent
esis.
B. Discomforttyattythetypuncturetysite
Rationale:tyMildt y discomfortt y att y thet y puncturet y sitet y ist y expectedt y aftert y at y thoracentesis.
C. Increasedtyhearttyrate
Rationale:tyClientstyaretyattyrisktyfortydevelopingtypulmonarytyedematyortycardiovasculartydistresstyduetymediastinalc ty
ontenttyshifttyaftertythetyaspirationtyoftyatylargetyamounttyoftyfluidtyfromtythetyclient'stypleuraltyspace.
Therefore,tythetyclienttymaytyexperiencetyantyincreasetyintyhearttyandtyrespiratorytyrate,tyalongtywithtyco
ughingtywithtyblood-
tingedtyfrothytysputum,tyandtytightnesstyintythetychest.tyThesetyfindingstyrequiretn y otificationtyoftythetyprov
idertyimmediately.
D. Decreasedtytemperature
Rationale:tyInfectiontyistypossibletyaftertyanytyinvasivetyprocedure;tyhowever,tyittytakestytimetytotydevelopty
andtyincreasestythetybodytytemperature.
Pagety3
, Detailed Answer Ke
ty ty
yMedical Surgical, A
ty ty ty
+
7. AtynursetyistycaringtyfortyatyclienttywhotyhastyatyhistorytyoftyexposuretytotyTBtyandtysymptomstyoftynighttysweatstyandtyhemop
tysis.tW
y hichtyoftythetyfollowingtyteststyshouldtythetynursetyrealizetyistythetymosttyreliabletytotyconfirm tythetydiagnosistyoftyacti
vetypulmonarytyTB?
A. Chesttyx-ray
Rationale:tyAtychesttyx-
raytymaytybetyhelpfultyfortydetectingtyoldtyortynewtylesionstythattyaretylargetyenoughtytotybetyvisualiz
ed.tyHowever,tythetyclienttywhotyhastyantyHIVtyinfectiontymaytyhavetyatynormaltyx-
raytyortyshowtyinfiltratestywhichtywouldtybetyexpectedtyintythetyclienttywhotyhastypneumonia.
B. Sputumtyculturetyfortyacid-fasttybacillus
Rationale:tyAlthought y thet y Mantouxt y (skint y test)t y andt y thet y chestt y x-
rayt y mayt y bet y usefult y screeningt y toolst y fort y TB,t y thetp
y resencetyoftyacid-
fasttybacillustynotedtyintythetyclient'stysputum,tysecretions,tyortytissuestyistythetyonlytymethodtythattycantya
ctuallytyconfirmtythetydiagnosis.
C. Sputumtysmear
Rationale:tyAt y sputumt y smeart y ist y ablet y tot y detectt y thet y presencet y oft y mycobacterium,t y butt y itt y doest y nott y distingui
shtby etweentymycobacterium tytuberculosistyandtyothertystrainstyoftymycobacterium.
D. Mantouxtytest
Rationale:tyThetyMantouxtyskintytesttyistyantyeffectivetyscreeningtytool,tybuttyittyistyunabletytotydistinguishtybetween
tyanta
y ctivetycasetyoftyTBtyandtyatyclienttywhotyhastybeen,tyattysometytimetyintythetypast,tyexposedtytotyTB
.tyThetyresultstyaretyalsotyvariable,tydependingtyupontythetyskilltyoftythetynursetyadministratingtyandtyr
eadingtythettyest.
8. Atynursetyintyatymedicaltyclinictyistyprovidingtyteachingtytotyantyoldertyadulttyclienttywhotyhastyosteoarthritistythattyistyaffectin
gtyhertky nees.tyWhichtyoftythetyfollowingtyclienttystatementstyindicatestyantyunderstandingtyoftythetyteaching?
A. "Itycantyusetyeithertyheattyortyicetytotyhelptyrelievetythetydiscomfort."
Rationale:tyThetynursetyshouldtyreinforcetythattydifferenttytreatmenttymodalities,tysuchtyastyheattyortycoldtytherapy,ty
cantb
y etytriedtytotydeterminetywhichtyonetyistymoretyeffectivetyfortythetyclient.tyHeattyapplicationtycantyhelpt
ywithtymuscletyrelaxationtyintythetyareatyaroundtythetyaffectedtyjoint.tyThetyapplicationtyoftycoldtynumbstyn
ervetyendingstyandtydecreasestyjointtyinflammation.
B. "Ibuprofentyistythetyfirsttysteptyintymedicationtytherapytyfortyosteoarthritis."
Rationale:tyThet y nurset y shouldt y instructt y thet y clientt y thatt y thet y primaryt y medicationt y oft y choicet y fort y thet y treatmentt y
ofto
y steoarthritistyistyacetaminophen.tyNSAIDS,tysuchtyastycelecoxibtyandtyibuprofen,tymighttybetytriedtyifty
acetaminophentydoestynottycontroltydiscomfort.
C. "Ityshouldtylimittyphysicaltyactivitytytotypreventtyfurthertyinjury."
Rationale:tyThet y nurset y shouldt y encouraget y thet y clientt y tot y includet y aerobict y exerciset y andt y lowert y extremityt y stre
ngthtty rainingtyintotyhertydailytyregimen.tyThesetyactivitiestyhavetybeentyshowntytotyslowtythetyprogressionty
oftyosteoarthritistyandtyrelievetythetymanifestationstyoftythetydisorder.
D. "ItywilltyelevatetymytylegstybytyplacingtytwotypillowstyundertymytykneestywhentyItygotytotybed."
Rationale:
Pagety4
ty ty
yMedical Surgical, A
ty ty ty
+
1. A nurse is reviewing the cause of gout with a group of nurses. Which of the following statements should the nurse
make?
A. "Uric acid levels drop and calcium forms precipitate."
Rationale: With gout, clients have hyperuricemia, rather than a reduction in uric acid.
B. "Tophi form in the kidneys and they impair the excretion of uric acid."
Rationale: Tophi, or deposits in tissues near a joint, develop in chronic, late-stage gout. They are not part of
the primary disease process.
C. "The intra-articular deposition of urate crystals causes inflammation."
Rationale: Gout, or gouty arthritis, develops when urate crystals deposit in joints and tissues and cause
inflammation and pain.
D. "Articular cartilage thins, leading to splitting and fragmentation."
Rationale: Gout does not thin and fragment cartilage.
2. Atynursetyistyteachingtyatygrouptyoftyclientstyabouttyosteoarthritis.tyWhichtyoftythetyfollowingtyrecommendationstyshouldt
ythetn
y ursetyincludetyintythetyteaching?
A. UsetyEchinaceatytotymanagetyjointtypain.
Rationale:tyThet y nurset y mayt y includet y thet y uset y oft y complementaryt y andt y alternativet y therapiest y int y thet y teaching.
However,tyEchinaceatyistyusedtyfortythetytreatmenttyoftythetycommontycold,tynottyosteoarthritis.tyAlterna
tivettyherapiestythattyaretyusedtyfortyosteoarthritistyincludetyglucosamine,tychondroitin,tyandtytopicaltycap
saicin.
B. Applytyicetytotythetyjointtybeforetyexercising.
Rationale:tyThet y nurset y shouldt y recommendt y thatt y thet y clientst y begint y exercisingt y immediatelyt y followi
ngt y theta
y pplicationtyoftyheat.tyThistyreducestypaintyandtyimprovestymobility,tyallowingtyfortyincr
easedtyrange-of-
motiontyduringtyexercises.tyColdtyapplicationtymaytybetyappliedtyfollowingtyexercisetytotd y ecrea
setydiscomforttyandtyinflammation.
C. Maintaintyatyrecommendedtybodytyweight.
Rationale:tyObesitytyistyatyrisktyfactortyfortythetydevelopmenttyoftyosteoarthritis.tyMaintenancetyoftyantyidealtyweig
httyisto
y netywaytyatyclienttycantypreventtyaddedtyweartyandtyteartyontyjointstyandtypromotetyoveralltyjointty
health.
D. Reducetythetyamounttyoftypurinetyintythetydiet.
Rationale:tyThetynursetyshouldtyrecognizetythattylimitingtypurinetyintythetydiet,tywhichtyistyoftentyfoundtyintyorgantyme
ats,tiystyrecommendedtyfortyclientstywhotyhavetygout.
3. Atynursetyistycaringtyfortyatyclienttywhotyhastyhadtyatymyocardialtyinfarction.tyUpontyhistyfirsttyvisittytotycardiactyrehabilitatio
n,tyhettyellstythetynursetythattyhetydoesn'ttyunderstandtywhytyhetyneedstytotybetytheretybecausetytheretyistynothingtymoretytoty
do,tyastythe
Pagety1
,Detailed Answer Ke
ty ty
yMedical Surgical, A
ty ty ty
+
damagetyistydone.tyWhichtyoftythetyfollowingtyistythetycorrecttynursingtyresponse?
A. "Cardiactyrehabilitationtycannottyundotythetydamagetytotyyourtyhearttybuttyittycantyhelptyyoutygettybacktytotyyourtyprev
ioustlyeveltyoftyactivitytysafely."
Rationale:tyWithtythistyresponse,tythetynursetyusestythetytherapeutictycommunicationtytechniquetyoftypresentingrty
ealitytybytyindicatingtyhertyperceptiontyoftythetysituationtyfortythetyclient.
B. "It’stynottyunusualtytotyfeeltythattywaytyattyfirst,tybuttyoncetyyoutylearntythetyroutine,tyyou’lltyenjoytyit."
Rationale:tyWitht y thist y response,t y thet y nurset y illustratest y thet y nontherapeutict y communicationt y techniquet y oft y giv
ingtry eassurance,tythustydiscouragingtythetyclienttyfromtyfurthertycommunication.
C. "Exercisetyistygoodtyfortyyoutyandtygoodtyfortyyourtyheart."
Rationale:tyWitht y thist y response,t y thet y nurset y illustratest y thet y nontherapeutict y communicationt y techniquest y ofd
ty is
agreeingtyandtygivingtyadvice.
D. "Yourtydoctortyistythetyexperttyhere,tyandtyI’mtysuretyhetywouldtyonlytyrecommendtywhattyistybesttyfortyyou."
Rationale:tyWitht y thist y response,t y thet y nurset y illustratest y thet y nontherapeutict y communicationt y techniquet y ofd
ty ef
ending.
4. Atynursetyistycaringtyfortyatyclienttywhotyhastyhearttyfailuretyandtyatypotassiumtyleveltyofty2.4tymEq/L.tyThetynursetyshouldtyid
entifytywhichtyoftythetyfollowingtymedicationstyastythetycausetyoftythetyclient’stylowtypotassiumtylevel?
A. Furosemide
Rationale:tyFurosemidetyistyatyloopty(high-
ceiling)tydiuretictythattyinhibitstythetyreabsorptiontyoftysodiumtyandtychloridea
ty ndtyresultstyintydiuresis,tywh
ichtydecreasestypotassiumtythroughtyexcretiontyintythetydistaltynephrons.
Hypokalemiatyistyantyadversetyeffecttyoftyfurosemide.
B. Nitroglycerin
Rationale:tyAtypotassiumtyleveltyofty2.4tymEq/Ltyistynottyantyadversetyeffecttyoftynitroglycerin.tyNitroglycerintyistyav
ty asod
ilatortymedicationtytotytreattyangina.
C. Metoprolol
Rationale:tyAtypotassiumtyleveltyofty2.4tymEq/Ltyistynottyantyadversetyeffecttyoftymetoprolol.tyMetoprololty
istyatb
y eta-
blockertythattyslowstythetyhearttyratetyandtyimprovestycontractilitytyoftythetyhearttymuscle.
D. Spironolactone
Rationale:tySpironolactonetyistyatypotassium-
sparingtydiuretictymedication;tytherefore,tyhyperkalemiatyistyana
ty dversetyeffecttyoftythistymedication.
5. Atynursetyistycaringtyfortyatyclienttywhotyistypostoperativetyfollowingtyantyopentyreductiontyinternaltyfixationty(ORIF)tyoftyatyfem
urtyfracture.tyWhichtyoftythetyfollowingtyparameterstyshouldtythetynursetyincludetyintythetyevaluationtyoftythetyneurovasculartyst
atustyofttyhetyclient'styaffectedtyextremity?ty(Selecttyalltythattyapply.)
Pagety2
,Detailed Answer Ke
ty ty
yMedical Surgical, A
ty ty ty
+
A. Color
B. Temperature
C. Ecchymosis
D. Skintyintegrity
E. Sensation
Rationale:tyColortyistycorrect.tyClientstywhotyhavetysustainedtytraumatytotyantyextremity,tysuchtyastyatyfracture,tyarety
attyincreasedtyrisktyfortyneurovasculartycompromise.tyThetynursetyshouldtychecktythetycolortyoftythetyclie
nt'styaffectedtyextremitytyastyparttyoftythistyassessment.tyThetynursetyshouldtyidentifytypallortyortycyanosi
styoftythete
y xtremitytyastyantyindicationtyoftyperipheraltyneurovasculartydysfunctiontyandtyshouldtynotifytyt
hetyprovider.Temperaturetyistycorrect.tyClientstywhotyhavetysustainedtytraumatytotyantyextremity,tysucht
yastyatyfracture,tyaretyattyincreasedtyrisktyfortyneurovasculartycompromise.tyThetynursetyshouldtymonitort
ythetytemperaturetyoftythetyextremitytyastyatyparttyoftythistyassessmenttyandtyidentifytyskintythattyistycooltyo
rtycoldtytotythetytouchtyastyhavingtydecreasedtyperfusiontytotythetytissuestyoftythetyextremity,tywhichtyistyan
tyindicationtyoftpy eripheraltyneurovasculartydysfunction.tyThetynursetyshouldtyreporttyskintythattyistycooltyt
otythetytouchtytotythetyprovider.Ecchymosistyistyincorrect.tyEcchymosis,tyortybruising,tyistyantyexpectedtyf
indingtywithtylegtyinjuriestyandtyistynottyatycomponenttyoftyatyneurovasculartycheck.Skintyintegritytyistyinc
orrect.tyWhiletythetynursetyshouldtyassesstythetyincisiontyoftyatyclienttywhotyistypostoperativetyfollowingty
antyopentyreductiontyandtyinternaltyfixationtyoftythetyfemur,tyittyistynottyatycomponenttyoftyatyneurovascula
rtycheck.Sensationtyistycorrect.tyClientstywhotyhavetysustainedtytraumatytotyantyextremity,tysuchtyastyatyf
racture,tyaretyattyincreasedtyrisktyfortyneurovasculartycompromise.tyThetynursetyshouldtyassesstythetycli
ent'styextremitytyfortynumbnessto y rtytingling.tyThetynursetyshouldtyrecognizetydiminishedtypaintyortypares
thesiatyastyantyindicationtyoftydamagetytotythetynervestyortyperipheraltyneurovasculartydysfunctiontyandty
shouldtyreporttyittytotythetyprovider.
6. Atynursetyistymonitoringtyatyclienttyfollowingtyatythoracentesis.tyThetynursetyshouldtyidentifytywhichtyoftythetyfollo
wingtm
y anifestationstyastyatycomplicationtyandtycontacttythetyprovidertyimmediately?
A. Serosanguineoustydrainagetyfromtythetypuncturetysite
Rationale:tyAtysmalltyamounttyoftyserosanguineoustydrainagetyattythetypuncturetysitetyistyexpectedtyaftertyatty horacent
esis.
B. Discomforttyattythetypuncturetysite
Rationale:tyMildt y discomfortt y att y thet y puncturet y sitet y ist y expectedt y aftert y at y thoracentesis.
C. Increasedtyhearttyrate
Rationale:tyClientstyaretyattyrisktyfortydevelopingtypulmonarytyedematyortycardiovasculartydistresstyduetymediastinalc ty
ontenttyshifttyaftertythetyaspirationtyoftyatylargetyamounttyoftyfluidtyfromtythetyclient'stypleuraltyspace.
Therefore,tythetyclienttymaytyexperiencetyantyincreasetyintyhearttyandtyrespiratorytyrate,tyalongtywithtyco
ughingtywithtyblood-
tingedtyfrothytysputum,tyandtytightnesstyintythetychest.tyThesetyfindingstyrequiretn y otificationtyoftythetyprov
idertyimmediately.
D. Decreasedtytemperature
Rationale:tyInfectiontyistypossibletyaftertyanytyinvasivetyprocedure;tyhowever,tyittytakestytimetytotydevelopty
andtyincreasestythetybodytytemperature.
Pagety3
, Detailed Answer Ke
ty ty
yMedical Surgical, A
ty ty ty
+
7. AtynursetyistycaringtyfortyatyclienttywhotyhastyatyhistorytyoftyexposuretytotyTBtyandtysymptomstyoftynighttysweatstyandtyhemop
tysis.tW
y hichtyoftythetyfollowingtyteststyshouldtythetynursetyrealizetyistythetymosttyreliabletytotyconfirm tythetydiagnosistyoftyacti
vetypulmonarytyTB?
A. Chesttyx-ray
Rationale:tyAtychesttyx-
raytymaytybetyhelpfultyfortydetectingtyoldtyortynewtylesionstythattyaretylargetyenoughtytotybetyvisualiz
ed.tyHowever,tythetyclienttywhotyhastyantyHIVtyinfectiontymaytyhavetyatynormaltyx-
raytyortyshowtyinfiltratestywhichtywouldtybetyexpectedtyintythetyclienttywhotyhastypneumonia.
B. Sputumtyculturetyfortyacid-fasttybacillus
Rationale:tyAlthought y thet y Mantouxt y (skint y test)t y andt y thet y chestt y x-
rayt y mayt y bet y usefult y screeningt y toolst y fort y TB,t y thetp
y resencetyoftyacid-
fasttybacillustynotedtyintythetyclient'stysputum,tysecretions,tyortytissuestyistythetyonlytymethodtythattycantya
ctuallytyconfirmtythetydiagnosis.
C. Sputumtysmear
Rationale:tyAt y sputumt y smeart y ist y ablet y tot y detectt y thet y presencet y oft y mycobacterium,t y butt y itt y doest y nott y distingui
shtby etweentymycobacterium tytuberculosistyandtyothertystrainstyoftymycobacterium.
D. Mantouxtytest
Rationale:tyThetyMantouxtyskintytesttyistyantyeffectivetyscreeningtytool,tybuttyittyistyunabletytotydistinguishtybetween
tyanta
y ctivetycasetyoftyTBtyandtyatyclienttywhotyhastybeen,tyattysometytimetyintythetypast,tyexposedtytotyTB
.tyThetyresultstyaretyalsotyvariable,tydependingtyupontythetyskilltyoftythetynursetyadministratingtyandtyr
eadingtythettyest.
8. Atynursetyintyatymedicaltyclinictyistyprovidingtyteachingtytotyantyoldertyadulttyclienttywhotyhastyosteoarthritistythattyistyaffectin
gtyhertky nees.tyWhichtyoftythetyfollowingtyclienttystatementstyindicatestyantyunderstandingtyoftythetyteaching?
A. "Itycantyusetyeithertyheattyortyicetytotyhelptyrelievetythetydiscomfort."
Rationale:tyThetynursetyshouldtyreinforcetythattydifferenttytreatmenttymodalities,tysuchtyastyheattyortycoldtytherapy,ty
cantb
y etytriedtytotydeterminetywhichtyonetyistymoretyeffectivetyfortythetyclient.tyHeattyapplicationtycantyhelpt
ywithtymuscletyrelaxationtyintythetyareatyaroundtythetyaffectedtyjoint.tyThetyapplicationtyoftycoldtynumbstyn
ervetyendingstyandtydecreasestyjointtyinflammation.
B. "Ibuprofentyistythetyfirsttysteptyintymedicationtytherapytyfortyosteoarthritis."
Rationale:tyThet y nurset y shouldt y instructt y thet y clientt y thatt y thet y primaryt y medicationt y oft y choicet y fort y thet y treatmentt y
ofto
y steoarthritistyistyacetaminophen.tyNSAIDS,tysuchtyastycelecoxibtyandtyibuprofen,tymighttybetytriedtyifty
acetaminophentydoestynottycontroltydiscomfort.
C. "Ityshouldtylimittyphysicaltyactivitytytotypreventtyfurthertyinjury."
Rationale:tyThet y nurset y shouldt y encouraget y thet y clientt y tot y includet y aerobict y exerciset y andt y lowert y extremityt y stre
ngthtty rainingtyintotyhertydailytyregimen.tyThesetyactivitiestyhavetybeentyshowntytotyslowtythetyprogressionty
oftyosteoarthritistyandtyrelievetythetymanifestationstyoftythetydisorder.
D. "ItywilltyelevatetymytylegstybytyplacingtytwotypillowstyundertymytykneestywhentyItygotytotybed."
Rationale:
Pagety4
