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Exhibits

Data is evaluated to determine possible condition and appropriate interventions. Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client’s progress.

Answer and Explanation

The Correct Answer is []

Condition:

Postoperative infection

2 Actions:

Administer prescribed antibiotics.
Culture wound drainage.

2 Parameters:

Temperature.
White blood cell count.

Rationale for correct condition:

A postoperative infection is the most likely condition because the patient has elevated white blood cell count (11,000/mm³) and a slightly elevated temperature (99.8°F). These findings suggest a systemic inflammatory response, potentially from infection. The presence of a recent surgical wound increases the risk of bacterial contamination. The absence of redness or drainage does not rule out deeper tissue infection. The patient’s symptoms align with early signs of an infectious process.

Rationale for the two correct actions:

Administer prescribed antibiotics: Antibiotics target potential bacterial infection, which is critical to prevent further complications such as systemic infection or sepsis.
Culture wound drainage: This identifies the causative organism and guides appropriate antibiotic therapy. Even if the wound appears clean externally, culturing can confirm or rule out deeper infection.

Rationale for parameters to monitor:

Temperature: Monitoring temperature helps identify trends in fever, a common sign of infection progression or resolution.
White blood cell count: Elevated levels are a marker of infection or inflammation. Monitoring changes in WBC count can indicate if treatment is effective.

Rationale for incorrect conditions:

Surgical rash: A rash is not indicated in the notes, and the elevated WBC count and temperature do not suggest a dermatologic issue.
Contractures: No evidence suggests reduced mobility or positioning problems causing contractures.
Deep vein thrombosis (DVT): The client’s normal vital signs and lack of redness or swelling in the residual limb make DVT less likely.

Rationale for incorrect actions to take:

Request NPO prescription: There is no evidence of gastrointestinal issues or surgery requiring this intervention.
Elevate residual limb to reduce swelling: While useful in managing swelling, there is no current sign of significant limb edema requiring elevation.
Educate on incentive spirometer use: This is preventive for respiratory complications but unrelated to infection management.

Rationale for incorrect parameters to monitor:

Adherence to activity prescription: While important for recovery, it does not directly address infection.
Residual limb redness or swelling: Although relevant to infection, there is no current evidence of redness or swelling in the notes.
Pain intensity and characteristics: Pain is already being managed with morphine, and its current level (5/10) does not directly indicate infection.

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Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A reason: Replacing dietary table salt with salt substitutes is not specifically related to managing gout. Gout is caused by the accumulation of uric acid crystals in the joints, leading to inflammation and pain. The primary dietary factor influencing gout is purine intake, not sodium. While reducing sodium intake is generally beneficial for overall cardiovascular health, it does not directly impact uric acid levels or the management of gout. Therefore, recommending salt substitutes does not address the underlying cause or prevention of gout attacks. Moreover, some salt substitutes contain potassium chloride, which can have its own health implications, particularly for individuals with kidney issues.

Choice B reason: Encouraging active range of motion to limit stiffness is important for maintaining joint function in many conditions, but during an acute gout attack, the primary focus should be on reducing inflammation and pain. Gout attacks cause severe pain and swelling, particularly in the affected joint, and encouraging active movement during an acute phase can exacerbate the pain and inflammation. It is more appropriate to rest the affected joint and manage pain and inflammation with medications and other supportive measures. Once the acute phase has resolved, gradual reintroduction of movement and exercise can help maintain joint function and prevent long-term stiffness.

Choice C reason: Taking prescribed pain medication after exercising joints is not appropriate advice for managing gout. Pain medication, such as NSAIDs (nonsteroidal anti-inflammatory drugs), should be taken as prescribed by the healthcare provider to effectively manage pain and inflammation. It is crucial to follow the prescribed regimen for pain management, regardless of exercise or activity. Furthermore, during an acute gout attack, it is advisable to avoid activities that may aggravate the affected joint. Pain management should be proactive, and medications should be taken at regular intervals to maintain pain relief rather than in response to specific activities like exercise.

Choice D reason: Avoiding the consumption of wine, beer, and coffee is crucial for managing gout. Alcohol, particularly beer and wine, contains high levels of purines, which can increase uric acid production and exacerbate gout symptoms. Alcohol also promotes dehydration, which can lead to higher uric acid concentrations in the blood. Both of these factors can trigger gout attacks. Coffee has mixed effects on gout; while some studies suggest that moderate coffee consumption may not significantly impact uric acid levels, it is generally advised to be cautious with its intake. Educating the client to avoid or limit these beverages can help prevent future gout attacks and manage symptoms more effectively. Dietary modifications are a key component of gout management, and avoiding high-purine foods and beverages is essential in reducing the frequency and severity of gout attacks.

A. Take the client to the emergency department (ED) B. Apply the client's home oxygen C. Ensure that the client avoids salt intake for the rest of the day D. Check for a thrill and bruit at the client's dialysis access site

Correct Answer is A

Explanation

Choice A reason: Taking the client to the emergency department is crucial because missing a dialysis session can lead to severe complications such as fluid overload, high potassium levels, and other electrolyte imbalances. These conditions can be life-threatening and require immediate medical attention to stabilize the client.

Choice B reason: Applying home oxygen is not the most critical intervention in this scenario. While oxygen therapy might be necessary in some cases, it does not address the immediate risk of complications arising from missed dialysis.

Choice C reason: Ensuring that the client avoids salt intake for the rest of the day is important for managing fluid balance, but it is not the most urgent action needed in this situation. The client's lethargy and difficulty arousing indicate a more serious underlying issue that requires immediate medical evaluation.

Choice D reason: Checking for a thrill and bruit at the client's dialysis access site is important for assessing the patency of the access site, but it is not the most critical action in this scenario. The immediate concern is the client's lethargy and potential complications from missed dialysis, which necessitate emergency medical care.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who is experiencing a first gouty arthritis attack reports excruciating pain in the right great toe. The nurse inspects the inflamed joint and administers ibuprofen 800mg PO as prescribed. Which instruction should the nurse include in the discharge teaching?

Correct Answer is D

Explanation

A client with chronic kidney disease (CKD) missed dialysis yesterday to attend a funeral. The client's spouse calls the home health nurse and reports that the client is lethargic and hard to arouse. Which instruction is most important for the nurse to provide?

Correct Answer is A

Explanation

After teaching a client newly diagnosed with cholecystitis about recommended diet changes, the nurse evaluates the client's learning. Which food choices eliminated by the client indicate to the nurse that teaching has been successful?

A client receives a prescription for 2 liters of lactated Ringer's IV to be infused over 12 hours. The IV administration set delivers 20 gtt/mL. How many gtt/min should the nurse regulate the infusion? (Enter numerical value only. If rounding is required, round to the nearest whole number.)

A client is recovering from the surgical removal of glass in the right eye. Which intervention should the nurse implement immediately following the procedure?

The healthcare provider prescribes 100 mL of 0.9% normal saline to be infused within 15 minutes. The nurse should program the infusion pump to deliver how many mL/hr? (Enter numerical value only.)

The nurse observes an increased number of blood clots in the drainage tubing of a client with continuous bladder irrigation following a transurethral resection of the prostate (TURP). Which is the best initial nursing action?

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