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 A

Explanation

Choice A rationale
Describing the client’s exact words, “body-wracking dry cough” of 6 weeks duration, provides a clear and specific account of the client’s symptoms and concerns.
Choice B rationale
Expressing concern of “lung cancer” symptoms for the last 6 weeks is less specific and does not accurately capture the client’s primary symptom, which is the dry cough.
Choice C rationale
Presenting with a hacking nonproductive cough of 6 weeks duration is a clinical interpretation and does not use the client’s own words, which is important for accurate documentation.
Choice D rationale
An adult male presents with fears that he has “lung cancer” is a subjective interpretation and does not accurately describe the client’s primary symptom.

A. Offer to administer a laxative prescribed for PRN use. B. Obtain a prescription to catheterize the client’s bladder. C. Notify the healthcare provider of the rebound tenderness. D. Instruct the client in distraction and relaxation techniques.

Correct Answer is C

Explanation

Choice A rationale
Offering to administer a laxative prescribed for PRN use is not appropriate in this situation, as the presence of rebound tenderness suggests a more serious underlying condition, such as appendicitis.
Choice B rationale
Obtaining a prescription to catheterize the client’s bladder is not indicated, as the symptoms are related to abdominal pain and rebound tenderness, not urinary retention.
Choice C rationale
Notifying the healthcare provider of the rebound tenderness is the appropriate action, as this finding could indicate a serious condition such as appendicitis. Prompt medical evaluation and intervention are necessary.
Choice D rationale
Instructing the client in distraction and relaxation techniques may help manage pain, but it does not address the underlying cause of the rebound tenderness. Immediate medical evaluation is required.

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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?

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

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?