A nurse is planning care for a client who has rheumatoid arthritis and has moderate to severe pain in multiple joints. Which of the following actions should the nurse plan to take?
Perform ADLs for the client to promote rest.
Allow for frequent rest periods throughout the day.
Use heat to reduce joint inflammation.
Develop a daily schedule for acetaminophen up to 6 g/day that covers peak periods of pain.
The Correct Answer is B
A. Perform ADLs for the client to promote rest. This is incorrect because performing ADLs for the client can increase their dependence and decrease their self-esteem. The nurse should encourage the client to perform ADLs as much as possible, with assistance as needed, to maintain their function and mobility.
B. Allow for frequent rest periods throughout the day. This is correct because rest periods can help reduce fatigue and pain, as well as prevent joint damage and inflammation. The nurse should balance rest and activity for the client and avoid overexertion.
C. Use heat to reduce joint inflammation. This is incorrect because heat can increase inflammation and pain in acute rheumatoid arthritis. The nurse should use cold applications to reduce swelling and inflammation in acute episodes, and use heat for chronic stiffness and pain.
D. Develop a daily schedule for acetaminophen up to 6 g/day that covers peak periods of pain. This is incorrect because acetaminophen has a maximum daily dose of 4 g/day, and exceeding this dose can cause liver toxicity. The nurse should monitor the client's liver function and use other analgesics as prescribed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
Discarding the first 10 mL of urine is a common practice for obtaining a urine sample for certain tests, but it is not specifically necessary for a urine culture. In a urine culture, the goal is to obtain a sample directly from the bladder to identify any bacteria present, so discarding the initial urine is not necessary.
Choice B reason
Donning sterile gloves prior to the procedure is the appropriate action for the nurse to take. When catheterizing a toddler for a urine culture, it is essential to maintain a sterile procedure to reduce the risk of infection and ensure the safety of the child. Using sterile gloves is a crucial step in preventing contamination during the catheterization process.
Choice C reason
The size of the catheter (12-French) mentioned in option C may not be appropriate for a toddler. The size of the catheter used for a toddler would generally be smaller, depending on the age and size of the child. The appropriate catheter size should be determined based on the child's age and condition.
Choice D reason
EMLA cream is a topical anaesthetic cream used to numb the skin before certain procedures. While it might be appropriate in some cases, it is not typically used for catheterization procedures in toddlers. Catheterization is a quick procedure, and using EMLA cream may not be necessary or practical in this situation.
Correct Answer is C
Explanation
A. Incorrect. Obtaining capillary blood glucose level every 2 hr is appropriate for a client who has type 1 diabetes mellitus, but it does not address the ankle injury.
B. Incorrect. Checking the neurovascular status of the client's lower extremities every hour is important for a client who has an ankle injury, but it does not require clarification with the provider.
C. Correct. Applying a cold pack to the client's ankle for 30 min every hour can reduce swelling and inflammation, but it can also impair circulation and increase the risk of tissue damage in a client who has diabetes mellitus. Therefore, the nurse should clarify this prescription with the provider before implementing it.
D. Incorrect. Maintaining the affected ankle elevated and immobilized can help prevent further injury and promote healing, but it does not require clarification with the provider.
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