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A nurse is caring for a client in a provider's office.

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Condition:

Rheumatoid arthritis

Actions to Take:

Assess joints for warmth and redness.
Assess for paresthesias.

Parameters to Monitor:

Weight-bearing joints.
Decreased immunity.

Rationale:

Condition Choices

Osteoporosis: Osteoporosis primarily leads to bone demineralization and increased fracture risk rather than inflammatory joint pain, swelling, and systemic symptoms such as fever and fatigue. The client’s symptoms, including joint inflammation and subcutaneous nodules, are not characteristic of osteoporosis.
Osteoarthritis: Osteoarthritis typically presents with asymmetric joint involvement, stiffness that worsens with activity, and crepitus in weight-bearing joints. The client’s symptoms, including symmetric joint swelling, prolonged morning stiffness, and systemic inflammation markers, are more consistent with an autoimmune disorder like rheumatoid arthritis.
Rheumatoid arthritis: The presence of bilateral joint pain, stiffness, swelling, subcutaneous nodules, and elevated inflammatory markers (ESR and CRP) strongly suggests rheumatoid arthritis. The morning stiffness, systemic symptoms like fatigue and low-grade fever, and the impact on mobility further support this diagnosis.
Gout: Gout is characterized by acute, episodic joint pain, typically affecting the metatarsophalangeal joint of the big toe. The client’s symptoms are more widespread and chronic, involving multiple joints and systemic inflammation, which is not typical of gout.

Actions to Take

Assess joints for warmth and redness: Inflammation in rheumatoid arthritis leads to synovial swelling, warmth, and redness. Regular assessment helps track disease progression and the effectiveness of treatment.
Assess for paresthesias: Chronic inflammation and joint deformities in rheumatoid arthritis can lead to nerve compression, resulting in numbness or tingling, particularly in the hands and feet.
Assess for crepitus in weight-bearing joints: Crepitus is more commonly associated with osteoarthritis due to cartilage degeneration. While rheumatoid arthritis affects weight-bearing joints, it does so through inflammatory destruction rather than mechanical wear.
Recommend the client spend at least 5 min outside in the sun daily: Sun exposure can help with vitamin D synthesis, but rheumatoid arthritis is not primarily related to vitamin D deficiency. This intervention is more relevant for osteoporosis management.

Parameters to Monitor

Weight-bearing joints: Rheumatoid arthritis commonly affects the knees, hips, and other weight-bearing joints, contributing to mobility issues and falls. Monitoring joint involvement helps assess disease progression.
Decreased immunity: Rheumatoid arthritis and its treatments, such as immunosuppressive medications, increase the risk of infections. Monitoring for signs of immunosuppression is essential for early intervention.
Joint inflammation in the big toe: This is more indicative of gout, which presents with acute episodes of pain and swelling in the first metatarsophalangeal joint rather than the widespread, chronic inflammation seen in rheumatoid arthritis.
Calcium and vitamin D levels: While important for bone health, these levels do not provide direct insight into rheumatoid arthritis progression. They are more relevant in osteoporosis management.
Cervical neck pain: While rheumatoid arthritis can affect the cervical spine, particularly at the atlantoaxial joint, the primary concern is peripheral joint inflammation and systemic symptoms rather than isolated neck pain.

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Correct Answer is D

Explanation

A. Infuse the unit of blood to the client over 6 hr: Blood transfusions should be completed within 4 hours to reduce the risk of bacterial growth and hemolysis. Prolonged infusion times increase the likelihood of complications such as infection or reduced efficacy of the transfused blood.

B. Prime the blood administration IV tubing with lactated Ringer’s: Blood products should only be primed and infused with normal saline (0.9% sodium chloride) to prevent hemolysis and clot formation. Lactated Ringer’s contains calcium, which can cause clotting in the blood product, increasing the risk of complications.

C. Check the first set of vital signs 30 min after the blood infusion is started: The nurse should check the client’s vital signs before initiating the transfusion, then again within the first 15 minutes. The highest risk of transfusion reactions occurs within this period, requiring close monitoring for signs such as fever, chills, or hypotension.

D. Document the donation number of the unit of blood on the client’s electronic medical record: Accurate documentation of the blood unit’s donation number ensures traceability and accountability. This information is essential for tracking in case of transfusion reactions or recalls and is a standard safety practice in blood transfusion protocols.

A. 150 mL of greenish yellow NG drainage B. Client requests medication for nausea C. Urinary output of 250 mL over past 12 hr D. Hypoactive bowel sounds

Correct Answer is C

Explanation

A. 150 mL of greenish yellow NG drainage: This amount and color of drainage are expected after abdominal surgery, as bile-stained gastric contents can be present. It does not indicate a complication that requires provider notification.

B. Client requests medication for nausea: Nausea is a common postoperative symptom, often managed with antiemetics. While it should be addressed, it is not an urgent finding that requires immediate provider notification.

C. Urinary output of 250 mL over past 12 hr: Oliguria, defined as urine output less than 30 mL/hr (or less than 400 mL in 24 hr), suggests inadequate renal perfusion, possibly due to hypovolemia or acute kidney injury. This finding requires prompt provider notification.

D. Hypoactive bowel sounds: Reduced bowel activity is common after abdominal surgery due to anesthesia and opioid use. While monitoring is necessary, hypoactive sounds alone are not an urgent concern unless accompanied by other signs of ileus or obstruction.

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A nurse is preparing to administer a blood transfusion to a client. Which of the following actions should the nurse plan to take?

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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