Nokea
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.
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History and Physical
A 59-year-old male client presents to the clinic reporting pain in the right great toe. The client says that the pain feels like it is another attack of gout, which he has had on 2 other occasions in the last 4 months. The client tells the nurses that the pain started about 9 days ago in the evening and that it got very painful and swollen shortly thereafter. In the past, the gout attacks have resolved without treatment after about 5 days, but the client reports that his condition has not improved and that he is unable to walk or work without excruciating pain in the great toe joint. The client has type 2 diabetes mellitus, osteoarthritis, hypertension, obesity, and sleep apnea. Currently, the client takes daily metformin, daily aspirin, daily enalapril, and ibuprofen as needed for pain. The client reports that he has never smoked or used tobacco products. He does not use recreational drugs. Typically, he drinks 2 to 3 dark beers nightly.
The healthcare provider is considering medications to treat the client's gout.
A 59-year-old male client presents to the clinic reporting pain in the right great toe. For each medication used to treat gout, choose the most likely therapeutic outcome and the teaching associated with the medication.
- A. Colchicine: Reduces inflammation.
- B. Prednisone: Reduces inflammation.
- C. Naproxen: Reduces pain and inflammation.
- D. Allopurinol: Lowers uric acid levels.
Correct Answer: A,B,C,D
Rationale: Colchicine and prednisone reduce inflammation, naproxen alleviates pain and inflammation, and allopurinol prevents uric acid buildup, addressing both acute and chronic gout management.
Which dietary instruction is most important for the nurse to explain to a client who has had gastric bypass surgery?
- A. Reduce intake of fatty foods.
- B. Chew slowly and thoroughly.
- C. Eat small frequent meals.
- D. Sip fluids with each meal.
Correct Answer: C
Rationale: Small, frequent meals prevent stomach pouch stretching and dumping syndrome, optimizing nutrient absorption.
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.
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.
A client with stage IV bone cancer is admitted to the hospital for pain control. The client verbalizes continuous, severe pain of 8 on a 0 to 10 scale. Which intervention should the nurse implement?
- A. Educate client on signs and symptoms of narcotic dependency.
- B. Administer opioid and non-opioid medication simultaneously.
- C. Give maximum dosage when score reaches 10.
- D. Alternate IV and IM analgesic medications.
Correct Answer: B
Rationale: Combining opioid and non-opioid medications provides synergistic pain relief, optimizing control while minimizing opioid side effects.