RA with Joint Arthroplasty HESI case study

Which nursing intervention related to the scheduled bone scan is most important to implement?
Instruct Terry to increase fluid intake after the test.

Increasing fluid intake after a bone scan will help with elimination of the injected radioisotope. Terry should also be instructed that because the dose of radioisotope is minimal, no special precautions are necessary.

Which etiologic factor is related to the onset of rheumatoid arthritis?
Genetic predisposition.

Because the incidence of RA in persons with a positive family history is significantly greater than for the general population, genetic predisposition is probably a significant etiologic factor. In addition, increased stress has been linked to RA, and viral infections are believed to be a trigger for the onset of this autoimmune disease.

In addition to the bilateral swollen tender joints, weight loss, and fatigue, what additional manifestation(s) of RA might Terry exhibit? (Select all that apply)
Joint deformities; Fever.

Joint deformities and subcutaneous nodules are common in advanced RA. A persistent low-grade fever is a common early manifestation of this inflammatory disease. Remember, RA is both a local and systemic inflammatory disease with many generalized symptoms such as fever, fatigue, and weakness, along with multiple lung, cardiac, and renal manifestations.

Which assessment findings may indicate aspirin toxicity?
Ringing in the ears and confusion.

Symptoms of aspirin toxicity include tinnitus, confusion, weakness, GI bleeding, and diarrhea.

Which adverse effect of methotrexate places Terry at the highest risk for infection?
Neutropenia.

Decreased levels of neutrophils place the client at high risk for infection. The client with neutropenia should be instructed to institute measures to avoid infections.

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Which information should be included when teaching Terry how to manage her chronic pain?
Apply warm packs to affected joints.

Heat applications will increase blood supply to the joints, decrease pain, and increase mobility. Cold applications may also be used, primarily for acute pain flare-ups.

Which nursing intervention is best to implement for this nursing diagnosis?
Instruct Terry regarding the use of joint splints.

Joint splints provide rest and support for the joints while maintaining good anatomical alignment.

Which nursing intervention will promote improved coping for Terry?
Help Terry practice problem-solving techniques.

This is an important nursing intervention. Clients experiencing a high level of stress may need guidance to solve even simple problems. In addition, support groups are often beneficial for clients coping with chronic disease.

What is the nurse’s best response?
You seem very overwhelmed right now.

Clarification of Terry’s feelings is a therapeutic technique which will encourage further communication.

What is the nurse’s best response to this remark?
Have you considered the possibility of surgical joint replacement?

Making a client-focused suggestion offers Terry an alternative without being confrontational or belittling.

What is the best definition of arthroplasty?
Surgical joint replacement.

Arthroplasty is the term used for total joint replacement. Hip replacement is the most common joint arthroplasty, followed by knee replacement. Clients with rheumatoid arthritis may also benefit from elbow, wrist, or finger arthroplasty.

Which postoperative intervention should the nurse expect to implement?
Empty drainage from the suction device and record the output.

A drainage device, such as a Hemovac or Jackson-Pratt suction device, is put in place during surgery. The nurse should monitor the amount and nature of the drainage, and report excessive or abnormal drainage to the surgeon. In addition, the nurse should assess the surgical compression dressing, and mark any areas of drainage on the dressing.

Which assessment finding should be reported to the healthcare provider?
Presence of paresthesia bilaterally.

Paresthesia is an abnormal sensation such as numbness or tingling that may indicate neurovascular compromise. Following any trauma or invasive procedure of a lower extremity, adequacy of neurovascular function distal to the site must be assessed regularly. This includes assessment for the six Ps: Pulselessness, Pain, Pallor, Paresthesia, and Paralysis, as well as Prolonged (> 3 seconds) capillary refill.

Which instruction should the nurse include when teaching Terry about the PCA pump?
The pump is set to prevent you from receiving and overdose.

Terry needs to know that the lockout feature prevents an overdose of the analgesic, since this is often a fear that prevents adequate analgesia. However, the nurse will still need to monitor Terry for indications that the prescribed dose is not excessive.

Which intervention should the nurse implement first?
Assess Terry and rule out any possible complications.

The nurse should always assess the client first because pain may indicate a complication that requires medical intervention.

Which task can be delegated to the UAP?
Empty Terry’s catheter drainage bag and record her urinary output.

This is an activity that can be delegate to a UAP. Activities delegated to a UAP should fall within the intervention component of the nursing process, and should not require the expertise of a licensed nurse.

Which professional has prescriptive authority that can provide a prescription for a different analgesic?
Physician’s assistant.

A physician’s assistant (PA), working in collaboration with a physician, may legally prescribe medications.

What is the best nursing action in response to this prescription?
Contact the PA for clarification of this incomplete prescription.

This prescription is incomplete and requires clarification from the prescriber. Remember the five rights: right client, drug, dose, rout, and time. The PRN frequency (right time) is missing from this prescription. A correct medication prescription includes not only the five rights, but also the prescriber’s signature and the date and time written.

Which intervention should the nurse implement first?
Assess Terry’s vital signs, including her temperature.

Further assessment of Terry’s condition is the highest priority. The nurse should first assess Terry’s vital signs and the appearance of the surgical dressing.

Which intervention should the nurse prepare to implement?
Obtain wound and blood cultures.

Terry is exhibiting symptoms of sepsis. Infection is a significant postoperative problem following joint replacement. Wound and blood cultures should be obtained, antipyretics administered, and cooling packs applied to reduce the fever.

Which manifestation may indicate the onset of septic shock?
Restlessness.

Early signs of shock include agitation and restlessness resulting from cerebral hypoxia. The nurse should assess carefully for these early symptoms. Other manifestations may include pallor, diaphoresis, hypotension, tachypnea, and tachycardia.

The prescription for gentamicin (Garamycin) is in a 50 mL piggyback bag of 0.9% normal saline. How many mL/hr would the nurse set the infusion pump on to deliver the IV gentamicin (Garamycin) over 30 minutes?
100

50 mL/30 minutes = X mL/60 minutes
300 = 30X
X = 100 mL/hr

Which outcome is most important for this portion of the teaching plan?
Terry demonstrates the correct use of the crutches for ambulation and transfers.

The best method to evaluate that a skill has been learned is by the performance of a return demonstration by the client.

Which positioning indicates that the crutches are sized correctly?
Arms flexed 20 degrees, crutch top two finger-widths from axilla.

Correct positioning includes the arms flexed at no more than 30 degrees, with the tops of the crutches 2-3 finger-widths from the axilla when the crutch tips are at least 6 inches in front of the foot.

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