The nurse is teaching the client newly diagnosed with systemic lupus erythematous about the condition. Which statement by the client indicates teaching was effective?

"My energy level will increase over time."

"I need to avoid prolonged sun exposure."

"My medications will ultimately correct my problem"

"I do not need to make changes in my diet."

Answer and Explanation

The Correct Answer is B

A. "My energy level will increase over time.": Fatigue is one of the most common and persistent symptoms of systemic lupus erythematosus (SLE). Energy levels often fluctuate depending on disease activity, and clients may experience chronic fatigue rather than steady improvement.

B. "I need to avoid prolonged sun exposure.": Ultraviolet (UV) light can trigger lupus flares and worsen symptoms such as skin rashes, joint pain, and fatigue. Avoiding prolonged sun exposure and using sun protection is a key self-care measure in SLE.

C. "My medications will ultimately correct my problem.": Medications such as corticosteroids, immunosuppressants, and NSAIDs help control inflammation and manage symptoms, but they do not cure SLE. The disease is chronic and requires ongoing management rather than correction.

D. "I do not need to make changes in my diet.": While no specific diet cures lupus, a balanced diet rich in vitamins, minerals, and anti-inflammatory foods supports overall health. Dietary modifications may also help manage side effects of medications, so disregarding nutrition is not accurate.

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Correct Answer is A

Explanation

Rationale:

A. Placing the client in airborne isolation: The client’s symptoms strongly suggest pulmonary tuberculosis. Airborne isolation prevents transmission of Mycobacterium tuberculosis to healthcare workers and other clients, making infection control the first concern.

B. Obtaining sputum cultures: Sputum cultures are necessary to confirm TB diagnosis and guide treatment. However, cultures should be obtained only after the client has been placed in proper isolation to prevent potential spread of infection during the collection process.

C. Monitoring the client's fluid intake and output: While hydration status is important in clients with fever, weight loss, and decreased appetite, it is not an immediate priority compared to preventing transmission of a highly contagious airborne disease.

D. Assessing the client's temperature every 8 hours: Monitoring fever helps track infection severity but does not address the urgent risk of spreading TB. Infection control measures take precedence before routine monitoring can be performed.

A. Place the head of the patient's bed flat. B. Notify the healthcare provider. C. Milk the chest tube. D. Disconnect the system and get another.

Correct Answer is B

Explanation

A. Place the head of the patient's bed flat: Positioning the patient flat does not address the underlying issue of excessive bubbling. This intervention has no effect on the integrity of the chest tube system or on resolving the possible air leak.

B. Notify the healthcare provider: Excessive bubbling in the water seal chamber usually indicates an air leak in the chest tube system or from the patient’s lung. Prompt notification of the healthcare provider ensures timely evaluation and correction of the problem to prevent complications.

C. Milk the chest tube: Milking or stripping chest tubes is not recommended because it can create high negative pressures and damage lung tissue. This action does not correct excessive bubbling and may worsen patient outcomes.

D. Disconnect the system and get another: Disconnecting the system increases the risk of introducing air into the pleural space, potentially leading to a tension pneumothorax. Replacing the system may be needed, but it should not be done before assessing and notifying the healthcare provider.

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The nurse is teaching the client newly diagnosed with systemic lupus erythematous about the condition. Which statement by the client indicates teaching was effective?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

The nurse is assessing a patient with chest tubes connected to a drainage system. What should the first action be when the nurse observes excessive bubbling in the water seal chamber?

Correct Answer is B

Explanation

An order to start a heparin drip is received from a physician. The order is for 1,000 units heparin per hour. The solution strength is 20,000 units in 500 ml. D5NS. What should the electronic pump be set for?

A client diagnosed with Schizophrenia states, "The voices won't leave me alone!" Which of the following statements should the nurse make?

A patient taking a first generation anti-psychotic medication is noted to grimace and smack both lips. The patient's neck and shoulders twisting in a snakelike motion. What problem would the nurse suspect?

Which assessment finding indicates a tension pneumothorax, a complication of untreated pneumothorax?

A client with HIV is being discharged home and will begin receiving care in the home setting. During discharge education, which aspect of self-care should the nurse emphasize as the priority to help prevent complications?

A client with chronic obstructive pulmonary disease (COPD) is experiencing dyspnea and has a low PaO2 level. The nurse plans to administer oxygen as prescribed. Which statement is true concerning oxygen administration to a client with COPD?

While caring for a client with a chest tube, which nursing assessment would alert the nurse to a possible complication?

The client with schizophrenia taking antipsychotic medication is conversing with the nurse when the eye's roll back in a locked position and their jaw presents to be locked in one position. Which is the priority action by the nurse?