The nurse examines a client's right great toe. The joint is red, edematous, and very painful with limited range of motion. The client's serum uric acid levels are elevated. Which action should the nurse tell the client to make?

Encourage fluid intake.

Increase intake of red meat.

Measure urine output.

Splint the affected joint.

Answer and Explanation

The Correct Answer is A

A. Encouraging fluid intake is important in managing elevated uric acid levels and conditions like gout. Increased fluid intake helps dilute the uric acid in the blood and promotes its excretion through the kidneys, which can help reduce the frequency of gout attacks.
B. Increasing the intake of red meat is not advisable, as red meat is high in purines, which can exacerbate gout by increasing uric acid levels. Clients with elevated uric acid should avoid purine-rich foods to prevent worsening their condition.
C. While measuring urine output can be useful in monitoring kidney function, it does not directly address the elevated uric acid levels or the acute gout symptoms the client is experiencing.
D. Splinting the affected joint may help with pain management by immobilizing the joint, but it is not a primary intervention for reducing uric acid levels or preventing further gout attacks. The focus should be on managing the underlying cause.

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Correct Answer is ["B","C","D","E"]

Explanation

A. Capillary refill is not the time it takes to return to the client's normal color after releasing pressure
B. Use your thumbnail and press the nailbed proximal to the injury: This is the correct technique for assessing capillary refill. You should press on the nailbed until it blanches and then release the pressure.
C. Pressure placed on the nailbed should cause blanching (pale): When pressure is applied to the nailbed, it should turn pale. This is known as blanching.
D. Capillary refill is measured in seconds: The time it takes for the nailbed to return to its normal color is measured in seconds.
E. Normal should be within 3 seconds or 5 in the older adult: A normal capillary refill time is generally considered to be within 3 seconds. However, in older adults, it may take up to 5 seconds for the nailbed to return to its normal color.

A. Have the client lay flat while listening to the anterior surface of the chest B. Press the stethoscope's diaphragm firmly on the skin over each lung field C. Shave all chest hair that may distort sounds heard through the diaphragm D. Use the bell of the stethoscope to listen to the lung fields over lower lobes

Correct Answer is B

Explanation

A. Having the client lay flat while listening to the anterior surface of the chest may not provide the best assessment of lung sounds, especially if the client is uncomfortable or if the posterior lung fields are not assessed. A sitting position is generally preferred for lung auscultation.
B. Pressing the stethoscope's diaphragm firmly on the skin over each lung field is the correct technique for assessing lung sounds. The diaphragm is better suited for detecting high-pitched sounds, such as wheezes, crackles, and other adventitious lung sounds.
C. Shaving chest hair may reduce extraneous noise but is unnecessary in most cases. Pressing the diaphragm firmly can usually eliminate the interference caused by hair, and shaving is not a standard procedure for lung auscultation.
D. The bell of the stethoscope is used for detecting lower-pitched sounds, such as heart murmurs, not for lung auscultation. The diaphragm is the appropriate tool for assessing adventitious lung sounds in all lung fields.

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The nurse examines a client's right great toe. The joint is red, edematous, and very painful with limited range of motion. The client's serum uric acid levels are elevated. Which action should the nurse tell the client to make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["B","C","D","E"]

Explanation

A male client arrives at the clinic for a follow-up health assessment after recent antibiotic treatment for pneumonia without hospitalization. Which technique should the nurse implement to assess for adventitious lung sounds?

Correct Answer is B

Explanation

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