A client who has been taking colchicine calls the clinic with reports of an acute gout attack of the right great toe. The client has a history of kidney stones and esophageal reflux. Which finding warrants immediate intervention by the nurse?
Watery diarrhea.
Heart burn.
Confusion.
Hematuria.
The Correct Answer is C
Rationale:
A. Watery diarrhea: While a known side effect of colchicine toxicity, it is typically an early sign. It requires follow-up but is not the most urgent compared to neurological changes.
B. Heartburn: Esophageal irritation is a possible reaction due to colchicine's GI side effects, but this symptom is not immediately life-threatening.
C. Confusion: Neurological changes such as confusion may indicate severe colchicine toxicity or systemic complications like renal failure or CNS involvement, and warrant immediate evaluation.
D. Hematuria: Although significant in a patient with a history of kidney stones, hematuria is not the most urgent sign unless accompanied by flank pain, fever, or decreased output.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Assess for discomfort when procedure is completed: Pain assessment is important after the procedure, but it does not address intra-procedural safety. Preventing disruption of the sterile field during the procedure takes priority in this moment.
B. Verify that the client has given informed consent: While consent is essential, it should be obtained before starting the procedure. If the debridement is already underway, verifying consent is no longer the immediate focus for ensuring safety.
C. Instruct the client to keep hands under the sterile field: A mildly confused client may unintentionally contaminate the sterile field. Providing clear instructions to keep hands away helps preserve sterility and reduces the risk of infection.
D. Pour cleansing solution onto the sterile cloth field: Pouring solution directly onto the sterile cloth can compromise the integrity of the sterile field. Cleansing solutions should be poured into sterile containers, not directly on the field, to maintain proper technique.
Correct Answer is A
Explanation
Rationale:
A. Plan for a follow-up echocardiogram occurring in 4 to 6 weeks: Follow-up echocardiograms are standard to monitor for coronary artery aneurysms, which may develop even after treatment. Early detection is vital to prevent long-term cardiac complications.
B. Resume the toddler's normal immunization schedule: Live vaccines such as MMR and varicella should be delayed for at least 10 months after IVIG, as the therapy can interfere with vaccine efficacy. Non-live vaccines may proceed as scheduled.
C. Irritability and tinnitus are expected for up to 2 weeks: Irritability is common, but tinnitus is not a recognized symptom of Kawasaki disease or its treatment. Persistent symptoms should be reported rather than assumed to be expected.
D. Manage joint pain with a nonsteroidal antiinflammatory: Aspirin, not general NSAIDs, is typically used for inflammation and thrombosis prevention in Kawasaki disease. Use of other NSAIDs may interfere with aspirin’s antiplatelet effects.
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