A nurse is assessing a client who has a new diagnosis of SLE (Lupus). Which of the following findings should the nurse expect?

Weight gain

Systolic murmur

Alopecia

Petechiae on thighs

Answer and Explanation

The Correct Answer is C

A.   Weight gain is not a typical finding associated with SLE. Patients often experience weight loss due to decreased appetite, fatigue, or increased metabolism. Therefore, this choice is less likely to be expected.
B.   While some patients with SLE may develop cardiac complications, such as pericarditis or valvular disease, a systolic murmur is not a common or characteristic finding of the disease itself. This choice is not specifically indicative of SLE.
C.   Alopecia, or hair loss, is a common finding in patients with SLE. It can occur due to the disease itself or as a side effect of certain medications used in treatment. This choice is a typical manifestation of SLE.
D.   Petechiae can occur in SLE, particularly when there is thrombocytopenia (low platelet count) or vasculitis associated with the condition. While it is not as common as alopecia, it can still be an expected finding in some cases of SLE.

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Correct Answer is B

Explanation

A. While obtaining a sputum culture is important for diagnosing a potential respiratory infection, it is not the immediate priority. The patient’s vital signs and oxygenation status need to be assessed first to ensure safety and to inform clinical decisions.
B. Assessing the patient’s vital signs and oxygen saturation is critical in this situation. The symptoms of disorientation, chills, and chest pain could indicate a serious condition such as pneumonia or pulmonary embolism.
C. Gathering a complete history is valuable for understanding the patient's condition and underlying causes of symptoms. However, this action should follow immediate assessments of vital signs and oxygen saturation, especially in a potentially unstable patient.
D. Administering the pneumococcal vaccine is important for prevention but is not an urgent action in this acute situation. The patient’s current symptoms require immediate assessment and intervention rather than preventive measures.

A. TPN should flow through a filtered IV line B. No other drugs should be infused through the TPN line C. If TPN gets stopped or runs out, hang a bag of D10% W D. TPN IV tubing and bag should be changed every 24 hrs E. TPN should be administered through a central line

Correct Answer is ["A","B","D","E"]

Explanation

A. Using a filtered IV line helps remove any particulate matter that could be present in the TPN solution, reducing the risk of complications such as phlebitis or embolism.
B. TPN should have its own dedicated line to prevent incompatibilities and ensure the TPN solution is delivered without interference. Infusing other medications through the same line can lead to complications and reduce the effectiveness of TPN.
C. If TPN gets stopped or runs out, a bag of 5% dextrose in water (D5W) should be hung to prevent hypoglycemia. D10% is too concentrated and can cause hyperglycemia.
D. To minimize the risk of infection and maintain sterility, TPN bags and tubing should be replaced every 24 hours. This helps prevent bacterial growth in the TPN solution.
E. TPN is typically administered through a central line because it allows for the infusion of hypertonic solutions that can irritate peripheral veins. Central lines provide better access to larger blood vessels, reducing the risk of complications.

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A nurse is assessing a client who has a new diagnosis of SLE (Lupus). Which of the following findings should the nurse expect?

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Naxlex Comprehensive Predictor Exams

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