A nurse is teaching a client diagnosed with gout about the new prescription for colchicine. Which of the following instructions should the nurse include in the teaching?

"Increase your intake of grapefruit juice."

"Expect to have increased generalized bruising."

"Monitor for muscle pain."

"Take this medication without food if nausea develops."

Answer and Explanation

The Correct Answer is C

A. "Increase your intake of grapefruit juice."

Grapefruit juice can interact with many medications, including colchicine, potentially increasing the risk of adverse effects or reducing its effectiveness. Therefore, it is not recommended to increase grapefruit juice intake while taking colchicine.

B. "Expect to have increased generalized bruising." Increased bruising is not a common side effect of colchicine.

C. "Monitor for muscle pain."

Colchicine is associated with myotoxicity, which can manifest as muscle pain or weakness. Therefore, the client should be instructed to monitor for signs and symptoms of muscle pain and report them promptly to their healthcare provider.

D. "Take this medication without food if nausea develops."

While colchicine can cause gastrointestinal side effects such as nausea and vomiting, taking it without food may exacerbate these symptoms. It is generally recommended to take colchicine with food to minimize gastrointestinal upset.

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Correct Answer is D

Explanation

A. Client develops petechiae on the arms, legs, and abdomen: Petechiae can indicate thrombocytopenia, which may be a complication of heparin therapy but is not an urgent concern unless severe or associated with bleeding.

B. Health care provider orders Coumadin 2.5 mg P.O. to begin today: Coumadin (warfarin) is often initiated as a bridge therapy or overlap with heparin therapy in pulmonary embolism management. This order is not necessarily inappropriate and may be part of the treatment plan.

C. Client develops slight ecchymosis at the venipuncture site: Ecchymosis at the venipuncture site can occur due to minor trauma during the insertion of IV lines or blood draws and is not necessarily indicative of a complication requiring immediate notification of the healthcare provider.

D. Client's partial thromboplastin time (PTT) is 70 seconds and the control is 25-40 seconds: A significantly elevated PTT indicates a potential overdose of heparin, putting the client at risk of bleeding complications. This finding warrants immediate notification of the healthcare provider for further evaluation and possible adjustment of heparin therapy.

A. Check an apical pulse B. Request a dietitian consult. C. Request an order for an antiemetic D. Suggest that the client rests before eating the meal

Correct Answer is A

Explanation

A. Check an apical pulse: Digoxin is known to cause toxicity, which can manifest as nausea, weakness, and anorexia. Bradycardia is a common sign of digoxin toxicity. Therefore, the nurse's first action should be to assess the client's apical pulse rate to determine if there are any signs of bradycardia, which could indicate digoxin toxicity.

B. Request a dietitian consult: While nutrition is important, the client's symptoms of nausea and weakness need immediate attention to rule out digoxin toxicity before considering dietary interventions.

C. Request an order for an antiemetic: Administering an antiemetic may be indicated if the client is experiencing nausea, but it's crucial to assess for digoxin toxicity first, as antiemetics may mask symptoms of toxicity.

D. Suggest that the client rests before eating the meal: Rest may be beneficial for the client, but addressing the potential cause of the symptoms, such as digoxin toxicity, takes priority

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A nurse is teaching a client diagnosed with gout about the new prescription for colchicine. Which of the following instructions should the nurse include in the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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