A nurse is planning care for a client who was recently admitted to the medical-surgical unit.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
The Correct Answer is []
Potential condition:
The client's admission assessment reveals symptoms consistent with SLE, such as fever, joint discomfort, malaise, macular rash on the cheeks, and generalized pain.
The laboratory results show an elevated erythrocyte sedimentation rate (ESR), which is a common finding in SLE.
Action to take:
In managing this condition, the nurse should ensure that the client has an intake of at least 200 mL/hr to maintain adequate hydration, which is crucial for patients with SLE to help prevent kidney damage from inflammation. Additionally, the nurse should encourage the client to avoid direct sunlight, as UV rays can exacerbate SLE symptoms.
Parameters to monitor:
To monitor the client's progress, the nurse should regularly check the erythrocyte sedimentation rate to assess the level of inflammation. Vital signs should also be monitored every 4 hours to ensure stability and detect any changes that may require medical intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A: A client who is scheduled for a colonoscopy and is taking sodium phosphate requires follow-up care because sodium phosphate can cause colonic mucosal damage and electrolyte imbalances that may affect the safety and accuracy of the colonoscopy. Sodium phosphate is a bowel preparation agent that empties the colon before the procedure, but it can also cause dehydration, kidney injury, and cardiac arrhythmias.
B: Induration following a Mantoux test indicates a reaction that may suggest tuberculosis exposure, but this is an expected result that requires assessment rather than immediate follow-up.
C: Bumetanide is a diuretic, and an increase in urination is an expected effect of this medication.
D: Warfarin is considered safe during lactation since it is not excreted in breastmilk to any measurable degree.
Correct Answer is C
Explanation
A. Transdermal nicotine patches should be applied immediately after removal from the protective pouch, but waiting for up to 1 hour is acceptable according to most manufacturers' instructions.
B. Shaving hairy areas of skin is not necessary prior to applying a transdermal nicotine patch and may cause skin irritation.
C. Wearing gloves during the application of the transdermal nicotine patch helps to prevent nicotine absorption through the nurse's skin and reduces the risk of accidental exposure.
D. The nurse should properly dispose of the previous patch according to facility protocols rather than placing it in a tissue, as used nicotine patches can still contain active medication and pose a risk of exposure.
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