Nokea
Orders
Laboratory Results
Day 1, 1000
Serum uric acid, blood urea nitrogen (BUN), creatinine (Cr)
X-ray of right foot
Day 1, 1015
Acetaminophen 650 mg PO now
Based on the client's laboratory findings, the nurse recognizes that the client is having an acute gout attack and is most at risk for SwellingBruisingInfectionInflammationRash and DiscolorationErythemaCyanosisPallorEcchymosis in his affected joint.
- A. Inflammation
- B. Discoloration
- C. Erythema Cyanosis
- D. Swelling
- E. Bruising
Correct Answer: A,B
Rationale: Inflammation and discoloration are hallmark symptoms of gout due to urate crystal-induced immune response and increased blood flow.
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A client who had colon surgery 3 days ago is anxious and requesting assistance to reposition. While the nurse is turning the client, the wound dehisces and eviscerates. The nurse moistens an available sterile dressing and places it over the wound. Which intervention should the nurse implement next?
- A. Bring additional sterile dressing supplies to the room.
- B. Auscultate the abdomen for bowel sound activity.
- C. Obtain a sample of the drainage to send to the laboratory.
- D. Prepare the client to return to the operating room.
Correct Answer: D
Rationale: Evisceration is a surgical emergency requiring immediate operative repair to prevent complications.
The nurse is preparing a client for surgery who was admitted from the emergency department following a motor vehicle collision. The client has an open fracture of the femur and is bleeding moderately from the bone protrusion site. During the preoperative assessment, the nurse determines that the client currently receives heparin sodium 5,000 units SUBQ daily. Which nursing action is a priority?
- A. Notify the healthcare provider of the client's medication history.
- B. Have the client sign the surgical and transfusion permits.
- C. Observe the heparin injections sites for signs of bruising.
- D. Ensure that the potential for bleeding is explained to the client.
Correct Answer: A
Rationale: Notifying the provider about heparin use is critical to manage perioperative bleeding risk due to its anticoagulant effects.
The nurse is teaching a client with glomerulonephritis about self-care. Which dietary recommendation should the nurse encourage the client to follow?
- A. Increase Intake of potassium rich foods such as bananas or cantaloupe.
- B. Restrict protein intake by limiting meats and other high protein foods.
- C. Limit oral fluid intake to 500 mL/day.
- D. Increase intake of high fiber foods, such as bran cereal.
Correct Answer: B
Rationale: Restricting protein reduces kidney workload and proteinuria, preserving function in glomerulonephritis.
Imaging Studies
Day 1, 1100
X-ray of right foot erosion of first metatarsal joint and preservation of joint space consistent with gout
The nurse is reviewing the client's dietary choices for opportunities to pro better outcomes by limiting gout attacks
Select the 3 dietary choices that are not part of the recommended diet gout.
- A. Shrimp
- B. Sardines
- C. Quinoa
- D. Oranges
- E. Oatmeal
- F. Spinach
- G. Liver
Correct Answer: A,B,G
Rationale: Shrimp , sardines , and liver are high in purines, which increase uric acid levels and should be avoided in gout management.
Nurses' Notes
Physical Examination
Vital Signs
Day 1, 0830
Body mass index (BMI) is 31.8 kg/m2
Pain rating of 8 on 0 to 10 scale, in the right foot
Client history has been collected, and the nurse performs a physical assessment and records vital signs
Which finding(s) in the client's health record should the nurse recognize places the client at a greater risk of developing gout? Select all that apply.
- A. Drinks beer nightly
- B. Hypertension
- C. Sleep apnea
- D. Ibuprofen for pain
- E. Daily aspirin
- F. Type 2 diabetes mellitus
- G. osteoarthritis
Correct Answer: A,B,F,G
Rationale: Beer , hypertension , diabetes, osteoarthritis increase uric acid levels or metabolic risks for gout.