Nokea
A client with recurrent episodes of gout has been advised to eat a low-purine diet. Which of the following foods should the nurse advise him to limit or avoid? Select all that apply.
- A. Liver.
- B. Sardines.
- C. Wine.
- D. Low-fat yogurt.
- E. Beef broth.
- F. Potatoes.
Correct Answer: A,B,E
Rationale: High-purine foods like liver (A), sardines (B), and beef broth (E) should be limited to reduce gout flare-ups. Wine (C), low-fat yogurt (D), and potatoes (F) are low in purines and generally safe.
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The nurse is teaching a client with a new diagnosis of atrial fibrillation about warfarin (Coumadin) therapy. Which of the following statements by the client indicates a need for further teaching?
- A. I will avoid eating large amounts of spinach.
- B. I will report any signs of bleeding to my doctor.
- C. I will take my medication at the same time each day.
- D. I will stop taking the medication if I feel dizzy.
Correct Answer: D
Rationale: warfarin should not be stopped without medical advice, as it increases the risk of clotting
The nurse is reviewing the lab reports on several clients. Which one should be reported to the physician immediately?
- A. A serum creatinine of 5.2 mg/dL in a client with chronic renal failure
- B. A positive C reactive protein in a client with rheumatic fever
- C. A hematocrit of 52% in a client with gastroenteritis
- D. A white cell count of 2,200 cu/mm in a client taking Dilantin phenytoin
Correct Answer: D
Rationale: A white cell count of 2,200 cu/mm indicates severe leukopenia, a serious side effect of Dilantin, requiring immediate reporting.
A homeless client has been admitted to the hospital for observation, and he does not speak any English. The nurse does not know any of the client's medical history, but he is grimacing and looks to be in pain. The nurse should
- A. use nonverbal communication such as pointing and gestures.
- B. call for the hospital interpreter services.
- C. give the client pen and paper and encourage him to draw.
- D. wait to see if any friends or family visit the client who may be able to help.
Correct Answer: B
Rationale: An interpreter ensures accurate communication for assessing pain and history, respecting patient needs and safety.
The nurse recognizes which of the following as the priority nursing diagnosis for the client in thyroid crisis?
- A. Risk for ineffective breathing pattern
- B. Risk for imbalanced body temperature
- C. Risk for decreased cerebral tissue perfusion
- D. Activity intolerance
Correct Answer: B
Rationale: Thyroid crisis (thyroid storm) causes hyperthermia, making imbalanced body temperature the priority due to the risk of life-threatening hypermetabolic complications.
The nurse receives an order for blood cultures and sensitivity for a client. Which statement is correct concerning this test?
- A. Preliminary test results are available 36 hours to allow the organisms time to grow.
- B. Growth and identification of the organism often takes 48 to 72 hours to complete.
- C. If the client has IV antibiotics infusing, stop the infusion before drawing blood cultures.
- D. If catheter sepsis is suspected, culturing the catheter tip is more accurate for identification.
Correct Answer: B
Rationale: Blood culture results typically take 48–72 hours for organism identification. Stopping antibiotics or culturing catheter tips is not standard practice.