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Medical Surgical, A+
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1.A nurse is reviewing the cause of gout with a group of nurses. Which of the following statements
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should the nurse make?
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A. "Uric acid levels drop and calcium forms precipitate."
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Rationale: With gout, clients have hyperuricemia, rather than a reduction in uric acid.
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B. "Tophi form in the kidneys and they impair the excretion of uric acid."
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Rationale: Tophi, or deposits in tissues near a joint, develop in chronic, late-stage gout. They
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are not part of the primary disease process.
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C. "The intra-articular deposition of urate crystals causes inflammation."
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Rationale: Gout, or gouty arthritis, develops when urate crystals deposit in joints and tissues
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and cause inflammation and pain. h h h h h
D. "Articular cartilage thins, leading to splitting and fragmentation."
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Rationale: Gout does not thin and fragment cartilage.
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2.A nurse is teaching a group of clients about osteoarthritis. Which of the following
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recommendations should the nurse include in the teaching?
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A. Use Echinacea to manage joint pain.
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Rationale: The nurse may include the use of complementary and alternative therapies in the
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hteaching.
However, Echinacea is used for the treatment of the common cold, not h h h h h h h h h h h
osteoarthritis. Alternative therapies that are used for osteoarthritis include
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glucosamine, chondroitin, and topical capsaicin.
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B. Apply ice to the joint before exercising.
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Rationale: The nurse should recommend that the clients begin exercising
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immediately following the application of heat. This reduces pain and
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improves mobility, allowing for increased range-of-motion during exercises.
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Cold application may be applied following exercise to decrease discomfort
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and inflammation. h h
C. Maintain a recommended body weight.
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Rationale: Obesity is a risk factor for the development of osteoarthritis. Maintenance of an
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ideal weight is one way a client can prevent added wear and tear on joints and
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promote overall joint health. h h h h
D. Reduce the amount of purine in the diet.
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Rationale: The nurse should recognize that limiting purine in the diet, which is often found in
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organ meats, is recommended for clients who have gout.
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3.A nurse is caring for a client who has had a myocardial infarction. Upon his first visit to cardiac
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rehabilitation, he tells the nurse that he doesn't understand why he needs to be there because
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there is nothing more to do, as the
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damage is done. Which of the following is the correct nursing response?
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A. "Cardiac rehabilitation cannot undo the damage to your heart but it can help you get back
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to your previous level of activity safely."
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Rationale: With this response, the nurse uses the therapeutic communication technique of
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presenting reality by indicating her perception of the situation for the client.
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B. "It’s not unusual to feel that way at first, but once you learn the routine, you’ll enjoy it."
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Rationale: With this response, the nurse illustrates the nontherapeutic communication
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technique of giving reassurance, thus discouraging the client from further
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communication. h
C. "Exercise is good for you and good for your heart."
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Rationale: With this response, the nurse illustrates the nontherapeutic communication
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techniques of disagreeing and giving advice.
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D. "Your doctor is the expert here, and I’m sure he would only recommend what is best for you."
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Rationale: With this response, the nurse illustrates the nontherapeutic communication
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technique of defending. h h h
4.A nurse is caring for a client who has heart failure and a potassium level of 2.4 mEq/L. The
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nurse should identify which of the following medications as the cause of the client’s low
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potassium level?
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A. Furosemide
Rationale: Furosemide is a loop (high-ceiling) diuretic that inhibits the reabsorption of sodium
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and chloride and results in diuresis, which decreases potassium through excretion
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in the distal nephrons. h h h h
Hypokalemia is an adverse effect of furosemide. h h h h h h
B. Nitroglycerin
Rationale: A potassium level of 2.4 mEq/L is not an adverse effect of nitroglycerin.
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Nitroglycerin is a vasodilator medication to treat angina.
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C. Metoprolol
Rationale: A potassium level of 2.4 mEq/L is not an adverse effect of metoprolol.
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Metoprolol is a beta-blocker that slows the heart rate and improves
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contractility of the heart muscle. h h h h h
D. Spironolactone
Rationale: Spironolactone is a potassium-sparing diuretic medication; therefore,
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hyperkalemia is an adverse effect of this medication.
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5.A nurse is caring for a client who is postoperative following an open reduction internal fixation
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(ORIF) of a femur fracture. Which of the following parameters should the nurse include in the
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evaluation of the neurovascular status of the client's affected extremity? (Select all that apply.)
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A. Color
B. Temperature
C. Ecchymosis
D. Skin integrity h
E. Sensation
Rationale: Color is correct. Clients who have sustained trauma to an extremity, such as a
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fracture, are at increased risk for neurovascular compromise. The nurse should
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check the color of the client's affected extremity as part of this assessment. The
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nurse should identify pallor or cyanosis of the extremity as an indication of
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peripheral neurovascular dysfunction and should notify the provider.Temperature
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is correct. Clients who have sustained trauma to an extremity, such as a fracture,
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are at increased risk for neurovascular compromise. The nurse should monitor the
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temperature of the extremity as a part of this assessment and identify skin that is
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cool or cold to the touch as having decreased perfusion to the tissues of the
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extremity, which is an indication of peripheral neurovascular dysfunction. The
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nurse should report skin that is cool to the touch to the provider.Ecchymosis is
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incorrect. Ecchymosis, or bruising, is an expected finding with leg injuries and is
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not a component of a neurovascular check.Skin integrity is incorrect. While the
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nurse should assess the incision of a client who is postoperative following an
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open reduction and internal fixation of the femur, it is not a component of a
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neurovascular check.Sensation is correct. Clients who have sustained trauma to
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an extremity, such as a fracture, are at increased risk for neurovascular
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compromise. The nurse should assess the client's extremity for numbness or
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tingling. The nurse should recognize diminished pain or paresthesia as an
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indication of damage to the nerves or peripheral neurovascular dysfunction and
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should report it to the provider.
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6.A nurse is monitoring a client following a thoracentesis. The nurse should identify which
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of the following manifestations as a complication and contact the provider immediately?
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A. Serosanguineous drainage from the puncture site h h h h h
Rationale: A small amount of serosanguineous drainage at the puncture site is expected after
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a thoracentesis. h h
B. Discomfort at the puncture site
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Rationale: Mild discomfort at the puncture site is expected after a thoracentesis.
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C. Increased heart rate h h
Rationale: Clients are at risk for developing pulmonary edema or cardiovascular distress due
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mediastinal content shift after the aspiration of a large amount of fluid from the
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client's pleural space.
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Therefore, the client may experience an increase in heart and respiratory rate,
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along with coughing with blood-tinged frothy sputum, and tightness in the chest.
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These findings require notification of the provider immediately.
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D. Decreased temperature h
Rationale: Infection is possible after any invasive procedure; however, it takes time to
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develop and increases the body temperature.
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