A preschool-age boy in a daycare facility scratches his head frequently, and the nurse confirms the presence of head lice. The nurse washes the child's hair with permethrin shampoo and calls his parents. Which instruction should the nurse provide to the parents about treatment for head lice?
Rationale:
The nurse should instruct the parents to wash the child's bed linens and clothing in hot soapy water. This is essential to eliminate lice and their eggs from the environment, preventing re-infestation. Heat and soap effectively kill lice on fabrics, which are common sources of transmission, ensuring comprehensive treatment alongside topical medication like permethrin shampoo.
A: Take the child to a hair salon for a shampoo and a shorter haircut. This does not address lice elimination or environmental cleaning, which are crucial aspects of treatment and prevention of reinfestation.
B: Rewash the child's hair following a 24-hour isolation period. Rewashing alone ignores the importance of environmental decontamination and does not guarantee eradication of lice from bedding and clothing.
D: Dispose of the child's brushes, combs, and other hair accessories. Disposing is unnecessary if items are properly cleaned or soaked, so this is an excessive and impractical recommendation.
A client with urolithiasis is preparing for discharge after lithotripsy. Which intervention should the nurse include in the client's postoperative discharge instructions?
Rationale:
Monitor the urinary stream for a decrease in output.
This instruction is essential because lithotripsy can cause ureteral obstruction from stone fragments. Monitoring urine flow helps detect any blockage early, preventing complications such as hydronephrosis or infection. Early identification of decreased output allows timely intervention, safeguarding kidney function and promoting recovery after the procedure.
A: Report when hematuria becomes pink-tinged. This is inaccurate since mild pink-tinged urine is expected post-lithotripsy and does not usually indicate a complication requiring immediate reporting.
B: Use an incentive spirometer. Incentive spirometry targets pulmonary function improvement and is unrelated to lithotripsy recovery or urinary system monitoring.
C: Restrict physical activities. Activity restriction is not routinely advised post-lithotripsy; moderate activity may aid stone passage and prevent complications like thrombosis.
The nurse assesses a male client with hyperthyroidism and identifies that the client has exophthalmos and lid retraction. Which pathophysiological factor is the likely cause of these findings?
Rationale:
Exophthalmos and lid retraction in a client with hyperthyroidism are caused by fluid accumulation. This swelling occurs due to increased glycosaminoglycan deposition and inflammation in the orbital tissues, leading to edema and protrusion of the eyeball. The pathophysiological process involves immune-mediated fluid retention and tissue expansion behind the eyes, characteristic of Graves' ophthalmopathy in hyperthyroid patients.
B: Ocular immobility results from muscle inflammation but does not directly cause exophthalmos or lid retraction; it primarily limits eye movement rather than causing swelling or protrusion.
C: Medication reaction is unrelated to the characteristic signs of exophthalmos and lid retraction, which are specific to the autoimmune effects in hyperthyroidism.
D: Bacterial infection typically causes localized redness and pain but does not produce the chronic swelling and tissue changes seen in hyperthyroid-related eye symptoms.
The nurse is caring for a client who had an appendectomy 4 hours ago. Which finding requires immediate action by the nurse?
Rationale:
High-pitched sound heard upon inspiration requires immediate action by the nurse. This finding suggests possible airway obstruction or respiratory distress, which can rapidly deteriorate the client’s condition and necessitates prompt assessment and intervention to ensure adequate oxygenation and prevent complications such as hypoxia or respiratory failure following surgery.
B: Apical heart rate of 100 to 110 beats/minute reflects mild tachycardia, which is common postoperatively due to pain or anxiety and usually does not require urgent intervention. It should be monitored but is not immediately threatening.
C: Redness and edema at the incision site indicate localized inflammation or early infection, which requires assessment but is not an emergency. These signs warrant monitoring and possible treatment but not immediate action.
D: Pain rating of 8 on a scale of 0 to 10 signifies severe pain needing management, but it is expected after surgery and does not pose an immediate threat to the client’s vital functions.
Laboratory Results
0600
Laboratory Test
Results
Reference Range
pH
7.23
7.35 to 7.45
Partial pressure of oxygen (PaO2)
89 mm Hg
80 to 100 mm Hg
Partial
37 mm
35 to 45
Based on the ABG values, the nurse knows that the client has [condition] related to [cause].
Rationale:
The client has uncompensated metabolic acidosis related to no insulin production.
The low pH (7.23) indicates acidosis, while the PaO2 is normal, and the partial pressure of CO2 (37 mm Hg) is within normal limits, showing no respiratory compensation. The absence of insulin causes metabolic acidosis due to the buildup of ketoacids, explaining the uncompensated state.
A: Compensated respiratory acidosis The pH is low, but CO2 is normal, showing no compensation. Respiratory acidosis would have elevated CO2 levels and compensatory renal response, which is absent here.
B: Compensated metabolic acidosis Normal CO2 and low pH indicate acidosis without respiratory compensation, so metabolic acidosis is uncompensated, not compensated, making this choice unsuitable.
C: Uncompensated respiratory acidosis CO2 is normal, excluding respiratory acidosis, which requires elevated CO2. Thus, this condition cannot be respiratory in nature.
E: Kussmaul respirations This describes a breathing pattern seen in metabolic acidosis but is not a diagnosis itself or related to insulin production directly.
F: Starvation Starvation may lead to ketosis but typically causes compensated states and does not explain absent insulin production or uncompensated acidosis here.
Dobutamine hydrochloride 2 mcg/kg/min is prescribed for a client weighing 165 pounds. The solution is mixed with 50 mg of dobutamine In 1,000 mL of DW. The nurse should set the Infusion pump to deliver how many mL/hour? (Enter numeric value only.)
Rationale:
The nurse should set the infusion pump to deliver 180 mL/hour.
This calculation converts the client's weight from pounds to kilograms (165 ÷ 2.2 = 75 kg), then multiplies by the prescribed dose (2 mcg/kg/min), resulting in 150 mcg/min. The concentration (50 mg in 1000 mL) equates to 50,000 mcg/1000 mL, so the rate is (150 mcg/min ÷ 50 mcg/mL) × 60 = 180 mL/hour.
A: 75 Delivering 75 mL/hour underestimates the necessary infusion rate based on dose and concentration calculations, failing to meet the prescribed mcg/kg/min dose accurately.
B: 120 This value does not correspond with the proper weight conversion and dosage calculations, resulting in insufficient medication delivery per minute.
C: 240 Setting 240 mL/hour exceeds the calculated dose, risking overdose by administering more than the prescribed mcg/kg/min.
The nurse assesses a client with petechiae and ecchymosis scattered across the arms and legs. Which laboratory result should the nurse review?
Rationale:
The nurse should review the platelet count. Platelets are critical for blood clotting, and low levels can lead to petechiae and ecchymosis due to impaired clot formation. Assessing platelet count helps identify thrombocytopenia or other platelet disorders, which directly correlate with these bleeding manifestations on the skin, guiding appropriate treatment and further diagnostic evaluation.
A: Hemoglobin levels measure oxygen-carrying capacity but do not reflect clotting ability or platelet function, making them irrelevant to petechiae and ecchymosis caused by bleeding disorders.
B: Red blood cell count indicates anemia or oxygen transport issues but does not influence bleeding tendencies or skin bruising characteristic of platelet abnormalities.
C: White blood cell count assesses infection or inflammation but does not affect clotting mechanisms or cause petechiae and ecchymosis related to bleeding.
The nurse is caring for a client who is admitted to the renal unit with pyelonephritis. The client is experiencing flank pain and fever upon admission. Which laboratory result supports the underlying pathophysiological mechanism that explains these findings? Reference Range: White blood cells (WBC) 5,000 to 10,000/mm³ (5 to 10 x 10â¹/L)
Rationale:
Urinalysis results hematuria and pyuria directly support the underlying pathophysiological mechanism causing flank pain and fever in pyelonephritis. This indicates inflammation and infection in the urinary tract, with white blood cells and blood cells present due to tissue damage and immune response.
A: Intravenous pyelogram (IVP) reveals free flowing urine. This finding does not directly indicate infection or inflammation but rather shows urine flow, unrelated to the immune response or tissue damage causing symptoms.
B: Microscopic sandlike granules in urine. These typically suggest crystalluria or kidney stones, not infection or inflammation, so they do not explain the fever and flank pain associated with pyelonephritis.
C: WBC count of 8,000/mm³ (8 x 10⁹/L). This value is within normal range, so it does not indicate the infection or immune activation expected in pyelonephritis causing fever and flank pain.
The nurse reviews discharge instructions with a client who has gastroesophageal reflux disease (GERD). Which instruction is most important for the nurse to emphasize?
Rationale:
Remaining upright following meals is most important because it helps prevent stomach acid from flowing back into the esophagus, reducing GERD symptoms and esophageal irritation. This position uses gravity to minimize reflux episodes, promoting healing and comfort. Maintaining an upright posture after eating is a fundamental behavioral modification that directly addresses the pathophysiology of acid reflux in GERD management.
A: Minimizing spicy foods can reduce irritation but doesn’t directly prevent acid reflux; it mainly lessens symptom severity rather than addressing the mechanical cause of GERD.
B: Smoking cessation improves overall health and esophageal function but is less immediately impactful on reflux compared to positional changes after meals.
C: Avoiding tight clothing reduces abdominal pressure but is a less significant factor than maintaining an upright posture to prevent acid reflux.
A client with a venire nurse take?
Rationale:
A client with a venire nurse should proceed with teaching the client how to walk with the crutches. This step is essential because after ensuring proper fit and adjustments, instructing the client on correct use promotes safety and effective mobility. Teaching walking techniques helps prevent falls and builds confidence, which is crucial for rehabilitation and independence during recovery.
A: Assess the client for signs of diminished circulation in the hands involves monitoring circulation but does not directly address crutch use or client education related to mobility training.
C: Ask the client to sit down while the crutch length is adjusted focuses on positioning but neglects the necessary step of teaching ambulation for practical crutch use.
D: Confer with the physical therapist for correct crutch size addresses proper sizing but overlooks the immediate need to instruct the client on how to walk safely using the crutches.
The nurse is caring for a client who is receiving teletherapy radiation for a malignant tumor. Which Instruction regarding skin care of the portal site should the nurse provide?
Rationale:
Protect the skin of the radiation portal site from sunlight exposure. Radiation causes the skin in the portal area to become more sensitive and susceptible to damage. Exposure to sunlight can exacerbate skin irritation, increase the risk of burns, and delay healing. Shielding the area from UV rays helps prevent complications and promotes skin integrity during teletherapy treatment.
A: Remove the ink marks of the portal after each radiation treatment. The ink marks serve as guides for precise radiation targeting and should remain intact to ensure consistent treatment delivery throughout the therapy course.
C: Apply moisture lotions daily to the radiation portal site. Moisturizers might interfere with radiation absorption or cause skin reactions; only prescribed or recommended products should be used under medical advice to avoid complicating skin care.
D: Avoid washing the skin inside the radiation portal site. Gentle washing is typically encouraged to maintain cleanliness and prevent infection; completely avoiding washing can lead to buildup of irritants and worsen skin condition.
The nurse is developing a plan of care for a client who reports blurred vision and who is newly diagnosed with cardiovascular disease. Which outcome should the nurse include in the plan of care for this client?
Rationale:
The client's daily blood pressure will be less than 140/80 mm Hg this month. This goal aligns with current guidelines for optimal blood pressure control in cardiovascular disease management, aiming to reduce complications like blurred vision. Achieving a target below 140/80 mm Hg effectively decreases cardiovascular risk and prevents further organ damage, making it a precise and measurable outcome for the nurse's care plan.
A: The client's blood pressure readings will be less than 160/90 mm Hg sets a less stringent target than recommended, potentially allowing continued risk for complications associated with cardiovascular disease and blurred vision.
B: The nurse will encourage the client to walk thirty minutes every day promotes healthy activity but does not directly specify measurable outcomes related to blood pressure control or symptom management.
C: The client's family will repeat signs and symptoms about the disease focuses on knowledge retention rather than a clinical outcome directly impacting the client’s cardiovascular health or vision status.
The nurse notes that there is a difference in a patient's blood pressure (BP) and heart rate (HR) when the patient changes position from supine to standing. The differences are a decrease of 20 mm Hg in systolic BP, a decrease of 10 mm Hg in diastolic BP, and an increase in the HR of 20 beats/minute. Which interpretation would the nurse make about the patient's condition?
Rationale:
An auscultatory gap explains the noted changes in blood pressure and heart rate when the patient moves from supine to standing.
B: An auscultatory gap is a temporary disappearance of Korotkoff sounds during BP measurement, causing inaccurate readings and apparent differences in BP and HR with position changes, consistent with the nurse’s observations.
A: Hypertensive crisis involves dangerously high BP levels, not a positional drop in BP and compensatory HR increase, which contrasts the patient’s observed decreases and rises.
C: Resistant hypertension refers to high BP uncontrolled by medications, not the acute positional BP drop and HR rise noted, indicating a measurement or physiological response issue.
D: Enlarged lymph nodes are unrelated to BP or HR changes and cannot explain the significant positional variations in cardiovascular parameters observed by the nurse.
Nurse's Notes
History and Physical
Orders
Vital Signs
Laboratory Results
Day 2, 0730:
Tolerated the surgical procedure well and has been stable since surgery.
Day 3, 0700:
Client is postoperative below-the-knee amputation of the right leg, sitting up with the right residual limb hanging off the bed. Morphine on demand in the left hand area; there is no redness or drainage at the site, with 50 mL per hour infusing. Assessment.
Exhibits
Data is evaluated to determine possible condition and appropriate interventions. Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client’s progress.
Data is evaluated to determine possible condition and appropriate interventions. Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
Your Selected Order (Tap items to remove)
Available Options (Tap to select in order)
A
Surgical rash.
B
Contractures.
C
Postoperative infection.
D
Deep vein thrombosis (DVT).
E
Actions to take
Choices
A. Culture wound drainage.
B. Request NPO prescription.
C. Administer prescribed antibiotics.
D. Elevate residual limb to reduce swelling.
E. Educate on incentive spirometer use.
F
Parameters to monitor
Choices
A. Adherence to activity prescription.
B. Temperature.
C. White blood cell count.
D. Residual limb redness or swelling.
E. Pain intensity and characteristics.
Rationale:
Postoperative infection is the most likely condition the client is experiencing.
Postoperative infection is identified by monitoring for redness, drainage, and elevated white blood cell count or temperature. Administering prescribed antibiotics and culturing wound drainage are appropriate nursing actions to treat and confirm infection presence. Monitoring temperature, white blood cell count, and wound site changes helps evaluate the infection’s progression or resolution effectively.
A: Surgical rash lacks signs of infection such as drainage or systemic symptoms, making it an unlikely diagnosis.
B: Contractures involve joint stiffness and limited mobility, which are not indicated by the current assessment focused on infection parameters.
D: Deep vein thrombosis involves limb swelling and pain, but there is no mention of these symptoms or risk factors in the notes.
The nurse calls the healthcare provider because a client diagnosed with an abdominal aortic aneurysm (AAA) is reporting low back pain. Which additional information about the client would be important for the nurse to tell the healthcare provider?
Rationale:
Low back pain in a client with an abdominal aortic aneurysm requires reporting hematocrit and blood pressure. Monitoring hematocrit helps detect internal bleeding, while blood pressure indicates aneurysm stability or rupture risk. These vital signs provide critical information for assessing the severity of the condition and guiding immediate medical intervention.
A: Calcium level and skin condition focus on metabolic and dermatological status, which are unrelated to acute complications or bleeding risks in abdominal aortic aneurysm cases.
C: White blood cell count and pulse rate monitor infection and heart rate but do not directly assess bleeding or aneurysm rupture indicators.
D: Serum amylase and level of consciousness evaluate pancreatic function and neurological status, which are not primary concerns in abdominal aortic aneurysm pain assessment.
A client presents to the emergency department reporting chest pain that is radiating to the left arm, shortness of breath, and diaphoresis. Which medication does the nurse anticipate being prescribed by the healthcare provider?
Rationale:
Morphine is the medication the nurse anticipates being prescribed for chest pain radiating to the left arm, shortness of breath, and diaphoresis. Morphine reduces myocardial oxygen demand by decreasing preload and alleviates pain, making it a standard treatment for acute coronary syndrome. It also helps relieve anxiety and pulmonary edema, improving patient comfort in emergency cardiac situations.
B: Oxycodone primarily treats moderate to severe pain but lacks specific cardiovascular benefits like preload reduction or anxiety relief, making it unsuitable for acute chest pain related to cardiac events.
C: Hydromorphone is a strong opioid analgesic used for pain management but does not address myocardial oxygen demand or pulmonary symptoms, thus not ideal for cardiac chest pain scenarios.
D: Fentanyl is a potent opioid used mainly for anesthesia and chronic pain, but it lacks the specific cardiac benefits of morphine in acute myocardial infarction settings.
A client is scheduled for a colonoscopy. Which instruction should the nurse provide regarding bowel preparation?
Rationale:
All of the above.
The nurse should instruct the client to drink only clear liquids the day before to ensure colon clarity, take the prescribed laxative to cleanse the bowel effectively, and avoid red-colored liquids to prevent misinterpretation during the procedure. These combined steps optimize visualization and accuracy in colonoscopy, ensuring thorough bowel preparation and minimizing complications.
A: Drink clear liquids only the day before. This advice is incomplete without laxative use and avoiding red liquids, which are essential for thorough bowel cleansing and accurate colonoscopy results.
B: Take the laxative as prescribed. Laxative use alone neglects necessary dietary restrictions and color avoidance, which are crucial to prevent procedural interference and ensure proper bowel visibility.
C: Avoid red-colored liquids. Avoiding red liquids alone does not address the need for dietary clarity and laxative-induced bowel cleansing, both vital for optimal colonoscopy preparation.
An adult who fell 20 feet (6 meters) from a tree is admitted to the intermediate intensive care unit with a fractured femur. When the cardiac monitor alarms, the nurse finds the client has no palpable carotid pulse and no spontaneous respiration, however, the cardiac monitor displays a sinus rhythm. Which intervention should the nurse implement?
Rationale:
Begin chest compressions at a rate of 120 times a minute. This is essential because the absence of a palpable carotid pulse and spontaneous respiration indicates cardiac arrest despite the sinus rhythm on the monitor, which may represent pulseless electrical activity. Immediate high-quality CPR supports circulation and oxygenation until advanced interventions can restore effective cardiac output and breathing.
A: View the rhythm in another chest lead. Changing leads does not address the absence of pulse and respiration, which are clinical signs requiring immediate resuscitation rather than further rhythm analysis.
C: Auscultate all chest fields for muffled lung sounds. Lung sounds do not guide immediate actions during pulselessness and apnea; prioritizing airway and circulation is critical instead of diagnostic auscultation.
D: Observe for swelling at the fracture site. While fracture assessment is important, it is not the priority when the patient lacks pulse and breathing, which necessitate immediate life-saving measures.
A client diagnosed with primary open-angle glaucoma received a prescription for miotic eye drops. Which instruction should the nurse plan to include in this client's teaching?
Rationale:
Miotic eye drops require careful handling, so the nurse should instruct the client not to allow the dropper bottle to touch the eye. This prevents contamination and reduces the risk of infection, ensuring safe and effective medication administration. Maintaining sterility of the dropper tip is crucial in managing primary open-angle glaucoma with miotic drops.
A: Wash your hands after each administration of eye drops. While hand hygiene is important, it is a general precaution and not specific to miotic eye drop use for glaucoma.
B: Squeeze your eye closed after administering the drops. This action is less relevant for miotic drops and does not directly impact medication absorption or safety in glaucoma treatment.
D: Administer the medication directly on the cornea. Placing drops directly on the cornea can cause irritation; drops are typically placed in the conjunctival sac, making this instruction inappropriate.
A patient who smokes reports chest pain while at rest. Which condition would the nurse suspect the patient is experiencing?
Rationale:
Prinzmetal angina is the condition the nurse would suspect in a patient who smokes and experiences chest pain at rest.
Prinzmetal angina involves coronary artery spasms causing transient chest pain typically occurring at rest, especially in smokers. This variant differs from exertional angina, as it arises independently of physical activity and results from vascular smooth muscle hyperreactivity rather than fixed atherosclerotic obstruction.
A: Silent ischemia lacks overt chest pain, making it unlikely in a patient reporting pain.
B: Angina decubitus occurs when lying down, not specifically linked to rest-related pain in smokers.
D: Chronic stable angina arises during exertion, not at rest, distinguishing it from this presentation.
The nurse is caring for a client with a diagnosis of Guillain-Barré syndrome (GBS). Which assessment finding is most consistent with this diagnosis?
Rationale:
Ascending paralysis starting in the legs is most consistent with Guillain-Barré syndrome (GBS). This condition typically presents as progressive weakness beginning in the lower extremities and advancing upward due to immune-mediated nerve damage. Early recognition of this pattern is crucial for prompt intervention and prevention of respiratory failure or further neurological decline in affected patients.
B: Sudden onset of severe headache aligns more with conditions like migraines or intracranial hemorrhages, lacking the characteristic motor weakness pattern found in GBS. Headaches do not define the typical GBS presentation.
C: Loss of vision in one eye suggests optic neuritis or multiple sclerosis, which primarily affects sensory and visual pathways, differing fundamentally from the motor paralysis seen in GBS.
D: Numbness and tingling in the hands indicate sensory disturbances that may occur, but GBS primarily features motor weakness beginning in the legs, making sensory symptoms alone insufficient for diagnosis.
Two weeks after returning home from traveling, a client presents to the clinic with conjunctivitis and describes a recent loss in the ability to taste and smell. The nurse obtains a nasal swab to test for COVID-19. Which action is most important for the nurse to take?
Rationale:
The nurse should isolate the client from other clients, family, and healthcare workers not wearing proper PPE. Isolation prevents further transmission of COVID-19, especially given symptoms like loss of taste and smell. Early isolation is critical to contain the virus, protect vulnerable populations, and ensure safety while awaiting test results, aligning with infection control protocols.
B: Report the COVID-19 result to the local health department according to CDC guidelines. Reporting occurs after diagnosis confirmation, not before isolation, so immediate containment takes precedence over notification to limit spread effectively.
C: Teach the client to wear a mask, hand wash, and social distance to prevent spreading the virus. While important, these preventive measures are secondary; immediate isolation is essential to reduce direct exposure risks in a clinical setting.
D: Explain to the client to inform others that they may have been potentially exposed in the last 14 days. Informing contacts is necessary but follows isolation; initial priority focuses on physical separation to minimize transmission during evaluation.
A client scheduled for coronary artery bypass surgery is to receive an intravenous infusion of 1 gram cefazolin in 50 mL 0.9% Sodium Chloride, USP over 30 minutes. The nurse should program the infusion pump to deliver how many mL/hour? (Enter numeric value only, as a whole number.)
Rationale:
The nurse should program the infusion pump to deliver 100 mL/hour.
This rate is calculated by dividing the total volume (50 mL) by the infusion time in hours (0.5 hours), resulting in 100 mL/hour. It ensures the medication is administered correctly over the 30-minute period for efficacy and safety during coronary artery bypass surgery preparation.
50: Infusing 50 mL/hour would deliver the dose over one hour, doubling the intended infusion time and delaying therapeutic effects.
25: Administering 25 mL/hour would extend the infusion to two hours, which is inconsistent with the prescribed 30-minute duration.
150: Delivering 150 mL/hour would shorten the infusion time to 20 minutes, increasing the risk of adverse reactions due to rapid administration.
While assisting a client to the toilet, the client begins to have a seizure and the nurse eases the client to the floor. The nurse calls for help and monitors the client until the seizing stops. Which intervention should the nurse implement first?
Rationale:
The nurse should first observe for prolonged periods of apnea. Monitoring the client’s breathing during a seizure is critical to ensure airway patency and prevent hypoxia, which can lead to serious complications. Immediate respiratory assessment allows prompt intervention if breathing stops, prioritizing the client’s safety over other concerns such as injury or documentation during the seizure event.
B: Observing for tongue lacerations is important but secondary to assessing airway and breathing. Immediate monitoring of respiratory status takes precedence to prevent life-threatening hypoxia during a seizure.
C: Documenting seizure details is necessary but should occur after stabilizing the client’s airway and breathing. It is not the first priority during an active seizure event.
D: Evaluating for incontinence provides useful clinical information but is not urgent. Ensuring the client’s airway and breathing during the seizure is the primary focus initially.
Filgrastim 5 mcg/kg/day subcutaneous is prescribed for a child with cancer who weighs 88 pounds. The medication is labeled 300 mcg/mL. How many mL should the nurse administer daily to this child? (Enter the numerical value only. If rounding is required, round to the nearest tenth.)
Rationale:
The nurse should administer 0.7 mL of filgrastim daily.
This calculation involves converting the child's weight from pounds to kilograms (88 ÷ 2.2 = 40 kg), then multiplying by the dose (40 kg × 5 mcg/kg = 200 mcg). Finally, dividing by the concentration (200 mcg ÷ 300 mcg/mL) results in 0.67 mL, rounded to 0.7 mL for administration.
A: 5.0 mL This volume exceeds the required dose by over seven times, indicating a significant dosing error that could lead to overdose and adverse effects.
B: 1.5 mL This amount more than doubles the calculated dose, risking potential toxicity and does not align with correct unit conversions or dosing calculations.
C: 2.0 mL Administering this quantity delivers more than three times the necessary dose, ignoring the correct weight-based dose and concentration ratio.
D: 0.5 mL This volume underestimates the dose, delivering less medication than required, which compromises therapeutic efficacy and patient treatment goals.
After a week of bed rest, a client is being assisted to a chair for the first time.The nurse raises the head of the bed and moves the client to a sitting position. What should the nurse implement next?
Rationale:
The nurse should determine how the client feels. Assessing the client's response to sitting up after prolonged bed rest is essential to identify symptoms like dizziness or weakness, which can indicate orthostatic hypotension or intolerance to position changes, ensuring safety before further activity or movement is attempted.
B: Support the client when rising provides physical assistance but comes after assessing their tolerance; premature support may overlook vital symptoms indicating instability or distress.
C: Offering non-skid socks enhances safety but does not address the immediate need to evaluate the client's physiological response to position changes.
D: Placing the chair by the bed facilitates transfer but is not the immediate next step; assessing the client’s condition takes precedence before moving.
A client with fluid volume overload is admitted to the hospital for diuresis. Which assessment should the nurse perform to evaluate the client's fluid balance?
Rationale:
Weight best evaluates fluid balance because it provides a direct, objective measure of fluid gain or loss over time. Daily weights help detect subtle changes in fluid status, guiding diuretic therapy effectiveness in clients with fluid volume overload. This approach is more precise than subjective or less sensitive assessments, ensuring accurate monitoring of fluid shifts during treatment.
A: Lung sounds assess pulmonary congestion but do not quantify overall fluid balance; they reveal respiratory complications rather than precise fluid volume changes.
B: Turgor evaluates skin elasticity, reflecting hydration status but not total body fluid volume or rapid fluid shifts in overload conditions.
D: Blood pressure fluctuates due to multiple factors and is not a reliable sole indicator of fluid volume changes in diuresis management.
The nurse should instruct a male client with which diagnosis that urinary frequency and nocturia are manifestations he is likely to experience?
Rationale:
Urinary frequency and nocturia are manifestations a male client is likely to experience with prostatic hyperplasia. This condition involves enlargement of the prostate gland causing obstruction of urine flow, leading to increased urinary urgency and nocturnal urination. The prostate's pressure on the urethra diminishes bladder emptying efficiency, resulting in these characteristic urinary symptoms commonly seen in aging males with this diagnosis.
B: Testicular torsion primarily causes acute scrotal pain and swelling, not urinary frequency or nocturia. It involves twisting of the spermatic cord, compromising blood flow rather than affecting urinary patterns or bladder function.
C: Inguinal hernia produces a protrusion in the groin area and discomfort but does not directly influence urinary frequency or nocturnal urination since it does not obstruct urinary pathways.
D: Scrotal hydrocele is fluid accumulation around the testicle causing scrotal swelling without impacting bladder function, thus it does not cause urinary frequency or nocturia in affected males.
The nurse is caring for a client with a burn that is severely edematous with a wound bed that is brown and yellow in appearance. The client expresses feeling no pain. Which classification of burn depth should the nurse document?
Rationale:
The burn should be documented as full-thickness. Full-thickness burns destroy both the epidermis and dermis, resulting in a wound bed that appears brown and yellow with severe edema. The absence of pain indicates nerve destruction, which aligns with full-thickness characteristics, distinguishing it from burns that preserve nerve endings and cause pain.
A: Deep partial-thickness burns usually cause significant pain because nerve endings remain intact, and the wound bed appears red or mottled, not brown and yellow.
C: Superficial partial-thickness burns affect only the epidermis and upper dermis, presenting with pain and redness rather than the described wound appearance or numbness.
D: Deep full-thickness burns extend below the dermis into subcutaneous tissue, which is more severe than the described presentation and often involves deeper tissue damage.
When entering a client's room, the nurse observes the client holding up an arm and coughing non-productively into the upper sleeve. Which action should the nurse take?
Rationale:
The nurse should obtain face masks for staff to wear upon entering the room. This action protects healthcare workers from potential airborne or droplet infections, especially since the client is coughing non-productively. Using masks minimizes transmission risk, aligning with infection control protocols when respiratory symptoms are present, ensuring safety for both staff and other patients in the healthcare environment.
A: Providing tissues does not fully prevent airborne droplet spread, especially during coughing episodes, thus insufficiently controlling infection transmission in clinical settings.
C: Changing the client’s gown does not address immediate respiratory droplet precautions or reduce exposure risks to staff entering the room.
D: Teaching the client to cover the mouth with hands can increase contamination on hands, potentially spreading pathogens through touch rather than reducing airborne exposure.
Nurses' Notes
Physical Examination
Vital Signs
Day 1, 0830
Body mass index (BMI) is 31.8 kg/m2
Pain rating of 8 on 0 to 10 scale, in the right foot
Client history has been collected, and the nurse performs a physical assessment and records vital signs
Which finding(s) in the client's health record should the nurse recognize places the client at a greater risk of developing gout? Select all that apply.
Your Selected Order (Tap items to remove)
Available Options (Tap to select in order)
A
Drinks beer nightly
B
Hypertension
C
Sleep apnea
D
Ibuprofen for pain
E
Daily aspirin
F
Type 2 diabetes mellitus
G
osteoarthritis
Rationale:
Drinks beer nightly, hypertension, type 2 diabetes mellitus, and osteoarthritis place the client at greater risk of developing gout.
These factors contribute to increased uric acid levels or decreased excretion, which are primary mechanisms in gout development. Alcohol, especially beer, raises purine intake. Hypertension and diabetes impair renal function, reducing uric acid clearance. Osteoarthritis involves joint damage, often associated with gout onset.
C: Sleep apnea does not directly influence uric acid metabolism or renal excretion linked to gout risk.
D: Ibuprofen treats inflammation but does not increase susceptibility to gout or affect uric acid levels.
E: Daily aspirin in low doses can mildly reduce uric acid excretion but is not a primary gout risk factor here.
The nurse is caring for a patient with a burn that is severely swollen, and the wound bed appears brown and yellow. The patient reports no pain. How should the nurse classify the depth of this burn?
Rationale:
This burn should be classified as full-thickness. Full-thickness burns destroy both the epidermis and dermis, resulting in a wound bed that can appear brown or yellow with severe swelling. The absence of pain occurs due to nerve damage. These characteristics distinguish full-thickness burns from other burn depths, aligning with the described clinical presentation.
A: Superficial partial-thickness burns affect only the epidermis and upper dermis, typically causing redness and pain, without severe swelling or brown-yellow wound beds.
C: Deep partial-thickness burns involve deeper dermal layers but still retain some sensation and do not usually present with brown-yellow wound beds or complete absence of pain.
D: Deep full-thickness burns extend beyond the dermis into subcutaneous tissue, often causing charring and leathery texture, which differs from the described burn’s presentation.
The nurse is assessing a client who has herpes zoster. Which question will allow the nurse to gather further information about this condition?
Rationale:
The nurse should ask, "Has everyone at home already had varicella?" to gather further information about herpes zoster. This question helps assess the risk of varicella-zoster virus transmission, as herpes zoster arises from reactivation of the virus, and exposure to susceptible individuals can lead to chickenpox, not shingles, guiding appropriate precautions and care.
A: Do your family members share combs and brushes? This question focuses on transmission modes unrelated to herpes zoster, which spreads through airborne droplets, not via personal items like combs or brushes, making it irrelevant for assessing this condition.
B: Do you have any dry patches on your feet and hands? This inquiry pertains to dermatological conditions such as eczema or psoriasis, unrelated to herpes zoster, which typically presents with painful, unilateral vesicular rash rather than dry skin patches.
D: Have the antifungal creams been effective? Antifungal treatments target fungal infections, whereas herpes zoster is viral; thus, asking about antifungal efficacy does not provide meaningful information regarding the management or symptoms of herpes zoster.
The nurse is assessing the lung sounds of a preschooler. Which action should the nurse implement to ensure the child's cooperation?
Rationale:
Allow the child to use a stethoscope on a stuffed animal. This approach familiarizes the preschooler with the equipment in a playful and non-threatening way, reducing anxiety and increasing cooperation during lung sound assessment. Engaging the child through imaginative play helps build trust and comfort, making the procedure smoother and more effective.
A: Have the child blow a cotton ball and have the parent catch it. This activity focuses on respiratory effort, not cooperation with auscultation, and may not alleviate the child's apprehension about the stethoscope.
C: Offer the child bubbles before the stethoscope is placed. Although bubbles can encourage deep breathing, this does not directly address the child’s comfort or engagement with the stethoscope during lung assessment.
D: Place a toy in the child's hands while listening to the breath sounds. Holding a toy distracts but does not actively involve the child in understanding or accepting the stethoscope, limiting its effectiveness in gaining cooperation.
A client with acquired immune deficiency syndrome (AIDS) and Pneumocystis jiroveci pneumonia has a CD4+ T cell count of 200 cells/mm³ (20%). The client asks the nurse why they have these recurring massive infections. Which pathophysiological mechanism should the nurse describe in response to this client's question?
Rationale:
Inadequate numbers of T lymphocytes are available to initiate cellular immunity and macrophages. This mechanism is central to AIDS pathophysiology, where CD4+ T cells are depleted, impairing the body's ability to activate macrophages and mount effective immune responses against opportunistic infections like Pneumocystis jiroveci pneumonia.
A: The humoral immune response lacks B cells that form antibodies and opportunistic infections result. This answer misattributes AIDS immune deficiency to B cells, whereas AIDS primarily affects T cell-mediated immunity, not antibody production.
C: Bone marrow suppression of white blood cells causes insufficient cells to phagocytize organisms. The primary issue in AIDS is T cell depletion, not bone marrow failure or generalized white blood cell production deficits.
D: Exposure to multiple environmental infectious agents overburdens the immune system until it fails. Immune failure in AIDS is due to viral destruction of CD4+ T cells, not simply cumulative exposure to pathogens.
A 19-year-old client is admitted to the hospital with severe right lower quadrant abdominal pain. The father is requesting to know his son's laboratory test results. Which is the best response for the nurse to provide?
Rationale:
The nurse should say, "I can only give medical information to your son because he is an adult." This respects patient confidentiality laws protecting adults' private health information, ensuring the nurse does not share details without the patient's consent. It clearly communicates legal boundaries, maintaining professional ethical standards in healthcare communication with family members.
A: I'm sorry but your son's medical information is none of your business. This is disrespectful and unprofessional, potentially damaging trust and failing to acknowledge the father's concern appropriately.
B: The healthcare provider will share this information with you. This implies the provider can disclose without the patient's consent, which violates confidentiality rules protecting adult patients.
D: I will get these results back from the lab as soon as possible. This avoids addressing the father's request directly and does not clarify the nurse’s limitations regarding sharing confidential information.
After noting that a patient with leukemia has thrombocytopenia, which action will the nurse plan to take?
Rationale:
Inspect skin for bruising or petechiae.
Thrombocytopenia causes a reduced platelet count, leading to impaired clotting and increased bleeding risk. Bruising and petechiae are common visible signs indicating bleeding under the skin. Monitoring these symptoms helps assess bleeding severity and guides nursing interventions to prevent complications in patients with leukemia and thrombocytopenia.
A: Palpate lymph nodes for swelling. This action primarily detects infection or lymphadenopathy, not directly related to platelet count or bleeding risk in thrombocytopenia patients.
B: Check temperature for elevation. Temperature assessment monitors infection presence but doesn’t specifically address bleeding manifestations linked to thrombocytopenia.
D: Examine oral mucosa for ulceration. Oral ulcers relate more to mucosal integrity or chemotherapy effects, not directly indicating platelet-related bleeding risks.
While caring for a client with full-thickness burns covering 40% of the body, the nurse observes purulent drainage from the wounds. Before reporting this finding to the health care provider, the nurse should evaluate which laboratory value?
Rationale:
The nurse should evaluate the neutrophil count before reporting purulent drainage from the wounds. Neutrophils are key components of the immune response to infection, and an elevated or decreased count can indicate the body’s ability to fight infection in a client with extensive burns. This helps prioritize treatment and guide the provider’s decisions.
A: Platelet count assesses clotting ability, which is unrelated to identifying infection or immune response in burn wounds. It does not provide immediate insight into the presence or severity of infection indicated by purulent drainage.
B: Serum albumin reflects nutritional status and protein reserves but does not directly indicate infection or immune function. It is not the primary lab value to assess when purulent drainage suggests possible wound infection.
D: Blood pH level measures acid-base balance, which is important for overall homeostasis but does not specifically evaluate immune response or infection status in burn wounds with purulent drainage.
The mother of a 6-year-old girl is concerned about her child's obesity. The child's weight plots at the 75th percentile, and height at the 25th percentile. The child's body mass index (BMI) is at the 85th percentile for age and gender. Which intervention(s) should the nurse implement? Select all that apply.
Rationale:
The nurse should obtain the child's 3-day diet history and determine the child's usual physical activity pattern.
Obtaining a detailed diet history helps identify nutritional excesses or deficiencies contributing to obesity, while understanding physical activity levels allows tailored recommendations to promote healthier habits, crucial for managing a BMI at the 85th percentile in a growing child with disproportionate weight and height percentiles.
B: Explain that the child is likely to grow into her weight. This assumes natural growth will resolve the issue without intervention, neglecting the need for active lifestyle and dietary assessment to prevent obesity-related complications.
C: Tell the mother that girls hit their growth spurt before boys so eating more is expected. This statement overlooks the child's current BMI percentile and does not address necessary assessments or interventions for obesity.
D: Inquire as to whether or not the school has a physical education program. While relevant, this option alone does not provide a comprehensive understanding of the child's individual diet and activity patterns needed for effective intervention.
The nurse educator is conducting a class for unlicensed assistive personnel (UAP). Which action indicates that a UAP understands gloving procedures?
Rationale:
Using sterile gloves when handling body fluids demonstrates proper gloving procedure, as it prevents contamination and protects both the client and healthcare worker from infection transmission. This practice aligns with infection control standards, emphasizing the necessity of glove use for potential exposure to infectious materials to maintain a safe care environment.
A: Dons sterile gloves when caring for clients with HIV. Sterile gloves are unnecessary for routine care of HIV clients; standard precautions with clean gloves suffice, as HIV transmission does not occur through casual contact.
C: Keeps a pair of gloves in uniform pocket. Storing gloves improperly risks contamination before use, compromising their protective barrier and defeating the purpose of infection control protocols.
D: Puts on new gloves when entering a client's room. Gloves should be donned before contact with bodily fluids or non-intact skin, not merely upon entering a room, to avoid unnecessary glove use and waste.
History and Physical
A 59-year-old male client presents to the clinic reporting pain in the right great toe. The client says that the pain feels like it is another attack of gout, which he has had on 2 other occasions in the last 4 months. The client tells the nurses that the pain started about 9 days ago in the evening and that it got very painful and swollen shortly thereafter. In the past, the gout attacks have resolved without treatment after about 5 days, but the client reports that his condition has not improved and that he is unable to walk or work without excruciating pain in the great toe joint. The client has type 2 diabetes mellitus, osteoarthritis, hypertension, obesity, and sleep apnea. Currently, the client takes daily metformin, daily aspirin, daily enalapril, and ibuprofen as needed for pain. The client reports that he has never smoked or used tobacco products. He does not use recreational drugs. Typically, he drinks 2 to 3 dark beers nightly.
The healthcare provider is considering medications to treat the client's gout.
A 59-year-old male client presents to the clinic reporting pain in the right great toe. For each medication used to treat gout, choose the most likely therapeutic outcome and the teaching associated with the medication.
Your Selected Order (Tap items to remove)
Available Options (Tap to select in order)
A
Colchicine: Reduces inflammation.
B
Prednisone: Reduces inflammation.
C
Naproxen: Reduces pain and inflammation.
D
Allopurinol: Lowers uric acid levels.
Rationale:
Colchicine, prednisone, and naproxen reduce inflammation or pain during acute gout attacks, while allopurinol lowers uric acid levels to prevent future attacks.
Colchicine specifically targets inflammatory pathways to alleviate acute gout symptoms quickly. Prednisone, a corticosteroid, suppresses immune response and inflammation. Naproxen, an NSAID, decreases pain and inflammation effectively. Allopurinol reduces uric acid production, preventing crystal formation and recurrent gout episodes over time.
A: Colchicine: Accurately reduces inflammation in acute gout, addressing symptoms without altering uric acid metabolism.
B: Prednisone: Effectively suppresses inflammation by modulating immune response, suitable for acute gout flares.
C: Naproxen: Provides analgesic and anti-inflammatory effects, easing pain and swelling associated with gout.
D: Allopurinol: Lowers uric acid levels to prevent attacks but does not relieve acute inflammation or pain immediately.
The nurse is caring for a male client with decreased circulation in the lower extremities. The client washes his feet in the shower but is unable to bend safely to dry the feet.While drying the client's feet, the nurse should emphasize the need to thoroughly dry which area of the feet?
Rationale:
Thoroughly drying between the toes is essential when caring for clients with decreased circulation in the lower extremities. Moisture trapped in these interdigital spaces can lead to fungal infections and skin breakdown, increasing the risk of complications. Proper drying prevents maceration and irritation, promoting skin integrity and reducing the likelihood of ulcers in vulnerable areas where moisture accumulates most.
A: On the dorsal surfaces Moisture accumulation on the dorsal surfaces is less common, and these areas are less prone to fungal infections compared to interdigital spaces, making this less critical for thorough drying.
C: Over the heels Although heels can develop pressure ulcers, they are not the primary sites for moisture-related infections, so drying here is important but not as crucial as between the toes.
D: Around the ankles The ankles typically do not retain moisture like interdigital spaces and are less susceptible to fungal growth, thus requiring less emphasis on drying compared to between the toes.
The nurse is initiating a prescription for Dextrose 2.5% in 0.45% Sodium Chloride (D2.5W, 0.45% NS) at 45 mL/hour for a child with dehydration. The nurse attaches a volume-control administration set with a microdrip chamber to the bag of solution. How many microdrops/minute should the nurse regulate the infusion? (Enter the numerical value only. If rounding is required, round to the nearest whole number.)
Rationale:
The nurse should regulate the infusion at 45 microdrops per minute.
This calculation uses the formula: (mL/hour × drip factor) ÷ 60 minutes. Using a microdrip set (60 gtt/mL), (45 × 60) ÷ 60 equals 45 drops per minute. Microdrip sets always deliver 60 drops per mL, making this the correct rate to accurately administer the prescribed infusion volume.
A: 27 Microdrops per minute would underdose the child, as it reflects half the required microdrip rate, risking insufficient fluid replacement during dehydration treatment.
B: 90 Microdrops per minute doubles the necessary infusion rate, potentially causing fluid overload and complications like electrolyte imbalance or pulmonary edema in the pediatric patient.
C: 30 Microdrops per minute underestimates the infusion speed, delivering less fluid than prescribed, which could delay rehydration and worsen the child's clinical condition.
An older adult female client is hospitalized with a fractured femur. During a routine nursing assessment, she repeatedly asks the nurse to "speak up" so that she can hear the questions. Which action is best for the nurse to take?
Rationale:
Decreasing speaking speed is best to help the client understand questions without straining to hear, allowing clearer auditory processing without causing distortion or discomfort. Slowing speech enhances comprehension, especially for older adults who may have hearing loss, facilitating effective communication and reducing the need for repeated requests to "speak up."
A: Over-enunciating syllables can sound unnatural and may confuse the client, making speech harder to follow rather than clearer, thereby not effectively addressing the hearing difficulty.
B: Raising voice volume to a shout risks startling the client and can distort sound quality, making it harder to understand rather than improving clarity.
C: Exaggerating nonverbal expressions might distract the client or seem patronizing, failing to directly improve auditory comprehension or address hearing challenges.
A postoperative client reports incisional pain. The client has two prescriptions for PRN analgesia that accompanied the client from the postanesthesia unit. Before selecting which medication to administer, which action should the nurse implement?
Rationale:
The nurse should compare the client's pain scale rating with the prescribed dosing. This ensures appropriate medication selection based on the severity of pain, promoting effective pain management and preventing under- or overdosing. Matching the pain level with the correct analgesic dosage prioritizes client safety and optimizes therapeutic outcomes by aligning treatment with the client’s reported pain intensity.
A: Determine which prescription will have the quickest onset of action prioritizes speed but neglects matching medication strength to the client's actual pain level, risking inadequate pain control or unnecessary side effects.
C: Document the client's report of pain in the electronic medical record is important but should follow assessment and medication selection, not precede it.
D: Ask the client to choose which medication is needed for the pain places decision-making on the client without clinical guidance, risking inappropriate medication use or delayed effective relief.
Which explanation should the nurse give to a male client on why benign prostatic hyperplasia (BPH) often causes urinary retention?
Rationale:
Benign prostatic hyperplasia often causes urinary retention because the enlarged gland compresses the urethra. This compression narrows the urethral passage, obstructing urine flow from the bladder, leading to difficulty in emptying the bladder completely. The mechanical blockage caused by the prostate's enlargement is the primary reason for urinary retention in BPH cases.
A: Nerve compression decreases the sensation that the bladder is full. This option misattributes urinary retention to sensory issues rather than structural obstruction, which does not align with the typical pathophysiology of BPH.
C: Abnormal growth results in loss of bladder muscle tone. This choice inaccurately focuses on bladder muscle weakening, which is not the main cause of retention in BPH, where obstruction is due to gland enlargement.
D: Inflammation causes spasms of the gland. This explanation incorrectly emphasizes inflammation and spasms, whereas BPH-related retention is mainly due to mechanical urethral compression by the enlarged prostate.
A young male adult walks into the emergency department (ED) holding a dead poisonous snake that bit him on his right calf within the last hour. After killing the snake, he tied a tablecloth about 4 inches (10 cm) above the bite. The client is now reporting numbness and tingling from the right knee to ankle. His heart rate is 123 beats/minute, respirations 28 breaths/minute, blood pressure 86/40 mm Hg, and oxygen saturation 94% on room air. Which intervention should the nurse implement?
Rationale:
Insert a large bore peripheral IV catheter.
This intervention is essential to establish rapid vascular access for fluid resuscitation and administration of antivenom, crucial in managing hypotension and systemic symptoms after a venomous snakebite. Early IV access supports stabilization of hemodynamics, compensates for shock, and facilitates emergency medication delivery, addressing the patient’s tachycardia, low blood pressure, and respiratory distress effectively.
B: Raise extremity above the heart. Elevating the limb increases venom spread via circulation, worsening systemic absorption and symptoms, which contradicts snakebite first aid principles aiming to slow venom distribution.
C: Tighten the cloth around the leg. Further constriction can cause ischemia and tissue damage, worsening local injury. The current cloth position may already impair circulation, risking compartment syndrome.
D: Apply ice over the bite mark. Ice can cause local vasoconstriction and tissue injury, delaying healing. It does not neutralize venom and is generally contraindicated in snakebite management.
While caring for a client with amyotrophic lateral sclerosis (ALS), the nurse performs a neurological assessment every four hours. Which assessment finding warrants immediate intervention by the nurse?
Rationale:
Weakened cough effort warrants immediate intervention by the nurse. This sign indicates declining respiratory muscle strength in ALS patients, increasing the risk of airway obstruction and respiratory failure, which requires urgent assessment and possible interventions to maintain airway patency and adequate ventilation for patient safety.
A: Inappropriate laughter reflects emotional lability common in ALS but does not pose immediate physical danger, thus not requiring urgent action.
B: Asymmetrical weakness is typical in ALS progression and does not signal an acute emergency needing immediate intervention.
C: Increasing anxiety may affect comfort but is not an immediate threat to life or neurological status, unlike respiratory compromise.
An elderly patient is admitted with an acute onset of diverticulitis, and intravenous antibiotic therapy is started. What should the nurse do next?
Rationale:
Maintain the patient's NPO status.
NPO status is essential after acute diverticulitis onset to rest the bowel and reduce gastrointestinal activity, preventing further irritation or perforation. Intravenous antibiotics are administered to treat infection, and oral intake could exacerbate symptoms or complicate treatment. This approach supports optimal healing before advancing diet or considering surgical interventions.
A: Elevate the head of the bed does not directly impact diverticulitis management or infection control in this acute phase, lacking relevance to bowel rest or symptom relief.
B: Initiate a bowel prep protocol for surgery is premature since surgery is not immediately indicated without complications; bowel prep may worsen inflammation.
C: Educate the patient on increasing dietary fiber is inappropriate acutely because fiber can aggravate symptoms; dietary changes are reserved for recovery or prevention phases.
A client is admitted to the medical unit during an exacerbation of systemic lupus erythematosus (SLE). It is most important to report which assessment finding to the health care provider?
Rationale:
Hematuria is the most important assessment finding to report because it may indicate lupus nephritis, a serious kidney involvement in systemic lupus erythematosus requiring prompt medical intervention to prevent renal damage. Early detection and treatment are crucial to preserving kidney function and preventing complications associated with exacerbations of SLE.
A: Joint pain is common in SLE exacerbations but usually manageable and less urgent compared to renal symptoms. It does not immediately threaten organ function.
C: Low grade fever may reflect inflammation or infection but is less specific and less critical than signs of kidney involvement like hematuria.
D: Muscle atrophy develops over time and is not an acute concern requiring immediate notification compared to active organ damage markers.