Professional Nursing Concepts and Challenges Test Bank

Correct Answer: A

Rationale: Swelling of the ankles (edema) is a common side effect of nifedipine (Procardia), especially when starting the medication. However, it is important for the client to understand that while edema is a known side effect, it is not considered normal and should be monitored. The client should report any significant or concerning swelling to their healthcare provider. Options B, C, and D demonstrate good understanding of the medication and its management.

Correct Answer: A

Rationale: Direct observation of behavior is the best way for the nurse to evaluate whether the client is able to set up and administer a nebulizer treatment. By directly observing the client, the nurse can assess the client's understanding and ability in performing the necessary steps correctly and safely. This approach allows for real-time evaluation and correction if needed, ensuring that the client can effectively manage their nebulizer treatment at home. Written or oral descriptions may not accurately reflect the client's actual competency in performing the task, and relying on the client's self-report during a follow-up appointment may not provide a complete picture of their ability.

Correct Answer: A

Rationale: In a patient with an acute attack of gout, the nurse should expect the uric acid level to be increased. Gout occurs due to the buildup of uric acid crystals in the joints, leading to inflammation and pain. Monitoring the uric acid level is important in diagnosing and managing gout, as elevated levels indicate an increased risk of crystal formation and gout attacks. Therefore, an increased uric acid level is a key laboratory finding in patients experiencing gout flares.

Correct Answer: D

Rationale: Passive range-of-motion exercises are beneficial in maintaining joint flexibility in clients with stroke. These exercises involve moving the client's limbs through a full range of motion, which helps prevent joint contractures and stiffness. Joint flexibility is crucial for maintaining mobility and preventing secondary complications such as pressure ulcers. While passive range-of-motion exercises may indirectly impact muscle strength, cardiorespiratory function, and endurance, the primary rationale for this intervention is to maintain joint flexibility.

Correct Answer: D

Rationale: The client recovering from knee replacement surgery has the greatest risk for developing deep venous thrombosis (DVT). Knee replacement surgery is a major orthopedic procedure that involves prolonged immobility and disruption of the normal blood flow in the lower extremities, which increases the risk of developing DVT. Postoperative patients are at a higher risk for developing blood clots due to reduced mobility, surgical trauma, and alterations in blood flow. Therefore, it is essential for healthcare providers to implement preventive measures to reduce the risk of DVT, such as early mobilization, compression stockings, and pharmacological prophylaxis.