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?

Increase intake of red meat.

Splint the affected joint.

Encourage fluid intake.

Measure urine output.

Answer and Explanation

The Correct Answer is C

Choice C rationale
Encouraging fluid intake is essential for clients with elevated serum uric acid levels, as it helps to dilute the urine and promote the excretion of uric acid, reducing the risk of gout attacks.
Choice A rationale
Increasing the intake of red meat is not advisable for clients with elevated serum uric acid levels, as red meat is high in purines, which can exacerbate gout symptoms.
Choice B rationale
Splinting the affected joint may provide temporary relief from pain, but it does not address the underlying issue of elevated serum uric acid levels.
Choice D rationale
Measuring urine output is important for monitoring kidney function, but it does not directly address the management of elevated serum uric acid levels.

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Correct Answer is C

Explanation

Choice A rationale
Restricting activity to bed rest is important but not the most immediate intervention for a client with a high fever and pain during deep palpation.
Choice B rationale
Monitoring urinary output is important but not the most immediate intervention in this scenario.
Choice C rationale
Initiating NPO (nothing by mouth) status is crucial to prepare the client for potential surgical intervention, especially if the pain suggests an acute abdominal condition.
Choice D rationale
Obtaining an electrocardiogram is important but not the most immediate intervention for a client with abdominal pain and high fever.

A. Number of blood clots expelled with each stool. B. Unique odor noted with gastrointestinal bleeding. C. Color characteristics of each stool. D. Evidence of internal hemorrhoids.

Correct Answer is C

Explanation

A. Number of blood clots expelled with each stool.Thisis not the most comprehensive approach as it focuses solely on clots without addressing other key aspects, such as stool color or consistency. Clots are also not always present with rectal bleeding.

B. Unique odor noted with gastrointestinal bleeding.While gastrointestinal bleeding, particularly upper GI bleeding, can produce a distinct odor, odor is subjective and not a reliable or standard assessment criterion to document.

C. Color characteristics of each stool.Stool color provides critical information about the source of the bleeding. For example, bright red blood (hematochezia) indicates lower GI bleeding, while black, tarry stools (melena) suggest upper GI bleeding. Documenting stool color helps in identifying the location and nature of the bleeding.

D. Evidence of internal hemorrhoids.While hemorrhoids are a common cause of rectal bleeding, the nurse cannot confirm the presence of internal hemorrhoids without diagnostic tools like anoscopy or sigmoidoscopy. The nurse should focus on documenting observable and measurable findings.

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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

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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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?