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.
The Correct Answer is C
- A. Encourage the client to take a cool sponge bath each morning is not correct because it can increase joint stiffness and pain.
- B. Administer opioid analgesia is not correct because it is not the first-line treatment for rheumatoid arthritis and can cause dependence and tolerance.
- C. Increase the client's dietary iron intake is indicate in rheumatoid arthritis due to anemia of chronic inflammation.
- D. Restrict the client's intake of foods high in purines is incorrect in rheumatoid. It is an important measure in gouty arthritis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
- A. Correct. The nurse should turn off the CPM machine during mealtime, as it can interfere with the client's ability to eat and drink comfortably. The nurse should also turn off the CPM machine when transferring or repositioning the client, or when performing wound care or other interventions on the affected leg.
- B. Incorrect. The nurse should maintain the client's affected hip in a neutral position, as external rotation can cause malalignment of the prosthesis and impair healing. The nurse should use pillows or wedges to support the leg and prevent rotation or abduction of the hip joint.
- C. Incorrect. The nurse should not instruct the client how to adjust the CPM settings, as this can compromise the prescribed range of motion and speed of the device. The nurse should follow the provider's orders and check with them before making any changes to the CPM settings. The nurse should also monitor the client's pain level and administer analgesics as needed to facilitate compliance with the therapy.
- D. Incorrect. The nurse should not store the CPM machine under the client's bed when not in use, as this can pose a safety hazard and damage the equipment. The nurse should place the CPM machine on a stable surface near the bed and ensure that it is plugged into a grounded outlet and has adequate battery backup in case of power failure.
Correct Answer is B
Explanation
A is incorrect because the completion of the incident report should not be documented in the client's medical record, but in a separate file for quality improvement purposes.
B is correct because the time the medication was given is an essential fact related to the incident that should be documented in the client's medical record.
C is incorrect because the reason for the medication error should not be documented in the client's medical record, but in the incident report for analysis and prevention of future errors.
D is incorrect because the notification of the pharmacist should not be documented in the client's medical record, but in the incident report for follow-up and corrective actions.
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