A nurse is planning care for a client who has rheumatoid arthritis. Which of the following interventions should the nurse include in the plan?

Encourage the client to take a cool sponge bath each morning.

Administer opioid analgesia.

Increase the client's dietary iron intake.

Restrict the client's intake of foods high in purines.

Answer and Explanation

The Correct Answer is C

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Correct Answer is ["B","F","G","H"]

Explanation

A. Bowel sounds are hypoactive in all four quadrants, which is expected after an appendectomy due to anesthesia and decreased peristalsis. This is not a finding that needs to be reported to the provider.

B. Oxygen saturation is 93% on room air, which is below the normal range of 95% to 100%. This could indicate impaired gas exchange, respiratory depression, or infection. This is a finding that needs to be reported to the provider.

C. Nausea is a common side effect of morphine and anesthesia, and can be managed with antiemetics and fluids. This is not a finding that needs to be reported to the provider unless it persists or interferes with oral intake.

D. Vomiting is also a common side effect of morphine and anesthesia, and can be managed with antiemetics and fluids. This is not a finding that needs to be reported to the provider unless it persists or interferes with oral intake.

E. Pain level is 6 on a scale of 0 to 10, which is moderate pain. The client received morphine as prescribed at 1815, and the pain level should be reassessed after 30 minutes. This is not a finding that needs to be reported to the provider unless the pain is unrelieved or increases.

- F. Heart rate is 110/min, which is above the normal range of 60 to 100/min. This could indicate pain, anxiety, dehydration, infection, or bleeding. This is a finding that needs to be reported to the provider.

- G. Incision characteristics are clean and dry, which is expected after an appendectomy. However, the nurse should monitor for signs of infection such as redness, swelling, warmth, drainage, or odor. This is a finding that needs to be reported to the provider if any signs of infection are present.

- H. Lungs sounds are clear on auscultation, which is expected after an appendectomy. However, the nurse should encourage deep breathing and coughing exercises to prevent atelectasis and pneumonia. This is a finding that needs to be reported to the provider if any abnormal lung sounds are heard such as crackles, wheezes, or diminished breath sounds.

A. Firmly massage the uterine fundus. B. Provide emotional support. C. Administer oxygen. D. Weigh the perineal pads. E. Insert indwelling urinary catheter. F. Administer methylergonovine. G. Administer terbutaline.

Correct Answer is ["A","B","C","D","E","F"]

Explanation

A: Correct. Firmly massaging the uterine fundus helps to contract the uterus and reduce bleeding.

B: Correct. Providing emotional support helps to calm the client and reduce anxiety, which can worsen bleeding.

C: Correct. Administering oxygen helps to improve tissue perfusion and oxygenation, which can be compromised by blood loss.

D: Correct. Weighing the perineal pads helps to quantify the amount of blood loss and monitor for hemorrhage.

E: Correct. Inserting an indwelling urinary catheter helps to empty the bladder and allow the uterus to descend and contract more effectively.

F: Correct. Administering methylergonovine helps to stimulate uterine contractions and control bleeding.

G: Incorrect. Administering terbutaline is contraindicated in this situation, as it relaxes the uterine smooth muscle and increases bleeding.

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A nurse is planning care for a client who has rheumatoid arthritis. Which of the following interventions should the nurse include in the plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["B","F","G","H"]

Explanation

Correct Answer is ["A","B","C","D","E","F"]

Explanation

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