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 D

Explanation

Choice A: This is incorrect. The client having difficulty reading large print indicates a need for an ophthalmology referral, not an occupational therapy referral. An ophthalmologist can assess and treat vision problems caused by stroke.

Choice B: This is incorrect. The client coughing while drinking from a straw indicates a need for a speech therapy referral, not an occupational therapy referral. A speech therapist can assess and treat swallowing problems caused by stroke.

Choice C: This is incorrect. The client being unable to bear her full weight while walking indicates a need for a physical therapy referral, not an occupational therapy referral. A physical therapist can assess and treat mobility problems caused by stroke.

Choice D: This is correct. The client becoming exhausted after performing activities of daily living indicates a need for an occupational therapy referral. An occupational therapist can assess and treat functional problems caused by stroke, such as fatigue, self-care, cognition, and leisure activities.

A. Replace the unit when the drainage chamber is full. B. Pin the tubing to the client's bed sheets. C. Monitor for at least 150 mL of drainage every hour. D. Clamp the tube for 30 min every 8 hr.

Correct Answer is A

Explanation

The correct answer is A:

Choice A reason:

Replace the unit when the drainage chamber is full. This ensures continuous, effective drainage. A full chamber cannot collect more fluid, risking system compromise and patient safety.

Choice B reason:

Pinning the tubing to the bed sheets is incorrect because it can cause kinks in the tubing, leading to obstruction of drainage and potential complications.

Choice C reason:

Monitoring for at least 150 mL of drainage every hour is not a standard practice. Normal chest tube drainage is variable; excessive drainage, such as 150 mL/hour, could indicate a serious condition like hemorrhage.

Choice D reason:

Clamping the tube routinely for 30 minutes every 8 hours is not recommended. Clamping may be done during tube removal or to check for air leaks but doing so routinely can lead to tension pneumothorax.

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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

Naxlex Comprehensive Predictor Exams

A nurse is assisting in the care of a client who had an ischemic stroke. Which of the following observations by the nurse indicates a need for an occupational therapy referral?

Correct Answer is D

Explanation

A nurse is assisting with the care of a client who has a closed-chest tube drainage system. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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