A nurse is assisting with the plan of care for a client who has osteoarthritis. The client reports knee pain that worsens with activity. Which of the following interventions should the nurse include in the plan of care?

Delay ambulation until the next day.

Apply moist heat prior to ambulation.

Use a continuous passive motion machine.

Restrict intake of dairy products.

Answer and Explanation

The Correct Answer is B

Choice A reason: Delaying ambulation until the next day is not an appropriate intervention, as it can cause stiffness, muscle weakness, or joint contractures in the affected knee. The nurse should encourage regular exercise and activity within the client's tolerance level to maintain joint mobility and function.

Choice B reason: Applying moist heat prior to ambulation is an appropriate intervention, as it can reduce pain and inflammation in the affected knee by increasing blood flow and relaxing the muscles and tendons around the joint.

Choice C reason: Using a continuous passive motion machine is not an appropriate intervention for osteoarthritis, as it is mainly used after knee replacement surgery to prevent scar tissue formation and improve range of motion in the new joint.

Choice D reason: Restricting intake of dairy products is not an appropriate intervention for osteoarthritis, as dairy products are good sources of calcium and vitamin D that can support bone health and prevent osteoporosis. The nurse should advise the client to eat a balanced diet that includes fruits, vegetables, whole grains, lean protein, and low-fat dairy products.

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Correct Answer is B

Explanation

Choice A reason: Chest x-ray showing cardiomegaly is not a new finding for the client who has heart failure, as it indicates enlargement of the heart due to increased workload and pressure on the cardiac chambers.

Choice B reason: PaCO2 55 mmHg is an abnormal finding for the client who has heart failure, as it indicates respiratory acidosis, which is a condition where the lungs cannot eliminate enough carbon dioxide and the blood becomes too acidic. This can be caused by pulmonary edema, which is a complication of heart failure that impairs gas exchange and ventilation.

Choice C reason: Potassium level 4.5 mEq/L is a normal finding for the client who has heart failure, as it indicates adequate electrolyte balance and renal function.

Choice D reason: Urinary output of 1,000 mL in 12 hr is a normal finding for the client who has heart failure, as it indicates adequate fluid status and cardiac output.

A. Maintain the client on bed rest. B. Reposition the client. C. Apply a warm, moist compress to the incision area. D. Administer an additional dose of pain medication.

Correct Answer is B

Explanation

Choice A: This is incorrect because maintaining the client on bed rest can increase the risk of complications such as pneumonia, thromboembolism, or pressure ulcers. The nurse should encourage early ambulation and frequent position changes to promote healing and prevent complications.

Choice B: This is correct because repositioning the client can help relieve pressure and discomfort from the incision site. The nurse should assist the client to change positions every 2 hours and use pillows or splints to support the incision.

Choice C: This is incorrect because applying a warm, moist compress to the incision area can interfere with wound healing and increase the risk of infection. The nurse should keep the incision site clean and dry and follow the provider's orders for dressing changes.

Choice D: This is incorrect because administering an additional dose of pain medication is not necessary when the client reports a pain level of 2 on a scale of 0 to 10. The nurse should monitor the client's pain level and administer pain medication as prescribed and as needed.

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A nurse is assisting with the plan of care for a client who has osteoarthritis. The client reports knee pain that worsens with activity. Which of the following interventions should the nurse include in the plan of care?

Nursing Test Bank

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