Nokea
A client with gout who was started on allopurinol a week ago calls the health care provider’s office with several concerns. The nurse should recognize which report by the client as being significant and requiring immediate follow-up?
- A. Also takes ibuprofen for pain
- B. Frequency of urination has increased
- C. Mild red rash has developed over torso
- D. Nausea occurs after each dose
Correct Answer: C
Rationale: A rash (C) may indicate a hypersensitivity reaction to allopurinol, potentially progressing to severe conditions like Stevens-Johnson syndrome, requiring immediate follow-up. Ibuprofen (A), urination (B), and nausea (D) are less urgent.
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The nurse has reinforced teaching about formula preparation with the parent of a newborn. Which of the following statements by the parent would indicate a correct understanding of the teaching? Select all that apply.
- A. I should avoid using the microwave to heat my baby's formula.
- B. I must wash the top of the concentrated formula can before opening it.
- C. If my baby is feeding poorly, I should use less water to dilute the formula.
- D. Prepared formula should be kept in the refrigerator and discarded after 24 hours.
- E. Bottled water does not need to be boiled when used to reconstitute powdered formula.
Correct Answer: A,B,D
Rationale: Microwaving (A) can cause uneven heating, risking burns, so it’s avoided. Washing the can top (B) prevents contamination. Refrigerated formula must be discarded after 24 hours (D) to prevent bacterial growth. Diluting less (C) alters nutrition, and bottled water (E) may need boiling depending on safety, indicating incorrect understanding.
The nurse is caring for a client with immune thrombocytopenic purpura. Which client statements indicate a need for further teaching? Select all that apply.
- A. I use a soft-bristle toothbrush and mild mouth rinse.
- B. I enjoy walking and wear nonskid footwear for safety.
- C. I use a safety razor and gentle shaving cream.
- D. I sometimes get constipated, so I have been taking docusate.
- E. I when I have a headache, I take over-the-counter ibuprofen.
Correct Answer: C,E
Rationale: ITP increases bleeding risk. Using a safety razor (C) risks cuts, and ibuprofen (E) inhibits platelets, both requiring further teaching. Soft toothbrush (A), safe walking (B), and docusate (D) are appropriate.
A visiting family member of a hospitalized client reports sudden onset of a headache and numbness in half of the body. The visitor asks the nurse to take a blood pressure reading. What is the most appropriate response by the nurse?
- A. Encourage the visitor to lie down to see if symptoms change
- B. Initiate protocol to assist the visitor to the emergency department
- C. Proceed to take the visitor's blood pressure
- D. Suggest that the visitor call the health care provider
Correct Answer: B
Rationale: Sudden headache and hemibody numbness suggest a possible stroke, a medical emergency requiring immediate evaluation. Initiating protocol to transfer the visitor to the emergency department (B) ensures timely care. Lying down (A), taking blood pressure (C), or calling a provider (D) delays critical intervention.
The nurse is caring for a client with hyperparathyroidism who had a parathyroidectomy 4 hours ago. Which technique should the nurse use to check for complications in this client?
- A. Ask the client to place the backs of the hands against each other to provide hyperextension of the wrist while the elbows remain flexed
- B. Perform the Romberg test by asking the client to stand with the eyes closed and the feet together
- C. Place a blood pressure (BP) cuff on the client's arm, inflate to pressure greater than systolic BP, and monitor for carpal spasm
Correct Answer: C
Rationale: Post-parathyroidectomy, hypocalcemia is a potential complication due to reduced parathyroid hormone levels. Trousseau’s sign (C), elicited by inflating a BP cuff to induce carpal spasm, indicates hypocalcemia, a critical complication requiring prompt intervention. The wrist hyperextension test (A) is unrelated to hypocalcemia, and the Romberg test (B) assesses balance, not relevant to this scenario.
A client admitted with glaucoma is being treated with miotic (pilocarpine) eye drops. Following administration of the medication, the nurse will note:
- A. Dilation of the pupils
- B. Diminished redness of the sclera
- C. Decreased edema of the cornea
- D. Constriction of the pupils
Correct Answer: D
Rationale: Miotics, such as pilocarpine, are administered to the client with glaucoma to cause pupillary constriction, thereby lowering intraocular pressure. Answer A is incorrect because miotics constrict the pupil. Answer B is incorrect because miotics do not diminish redness. Answer C is incorrect because miotics do not decrease edema of the cornea.