The nurse is preparing a client for surgery who was admitted from the emergency department following a motor vehicle collision. The client has an open fracture of the femur and is bleeding moderately from the bone protrusion site. During the preoperative assessment, the nurse determines that the client currently receives heparin sodium 5,000 units SUBQ daily. Which nursing action is a priority?

Have the client sign the surgical and transfusion permits.

Notify the healthcare provider of the client's medication history.

Ensure that the potential for bleeding is explained to the client.

Observe the heparin injections sites for signs of bruising.

Answer and Explanation

The Correct Answer is B

A. Having the client sign surgical and transfusion permits is important but not the priority in this situation.

B. Notifying the healthcare provider of the client's medication history, including heparin use, is crucial to ensure appropriate perioperative management and to prevent excessive bleeding during surgery.

C. Explaining the potential for bleeding to the client is important for informed consent but is not the priority in this situation.

D. Observing the heparin injection sites for signs of bruising is important but not the priority compared to notifying the healthcare provider about the client's medication history.

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Correct Answer is ["B","F","J"]

Explanation

A. Garlic is generally considered safe for individuals with gout.

B. Organ meats like liver are very high in purines and should be avoided in a diet for managing gout.

C. Spinach contains moderate amounts of purines, but newer research suggests that they may not increase the risk of gout attacks as much as once thought, and they provide other health benefits that can be weighed in dietary decisions.

D. Oatmeal is generally considered safe for individuals with gout.

E. Chicken is generally considered safe for individuals with gout.

F. Seafood, particularly shellfish like shrimp, is also high in purines and generally recommended to be limited or avoided in a gout diet.

G. Lentils contain moderate amounts of purines, but newer research suggests that they may not increase the risk of gout attacks as much as once thought, and they provide other health benefits that can be weighed in dietary decisions.

H. Quinoa is generally considered safe for individuals with gout.

I. Oranges is generally considered safe for individuals with gout.

J. Small oily fish such as sardines are another source of high purines and are often advised against in the diet of someone managing gout.

Correct Answer is []

Explanation

Potential condition: Retinopathy

Actions to take: Orient the client to the environment; Call for an ophthalmological exam

Parameters to monitor: Blood glucose; Visual acuity

Rationale:

Based on the patient data provided, the client is most likely experiencing retinopathy, particularly diabetic retinopathy, which is a common complication of diabetes and can lead to progressive vision loss. The elevated HBA1C level indicates poor blood glucose control, which can contribute to the worsening of this condition.

The nurse should call for an ophthalmological exam to confirm the diagnosis and assess the extent of retinal damage. Additionally, orienting the client to the environment is important to ensure safety due to the vision impairment. Monitoring the client's blood glucose levels is crucial for managing his diabetes and potentially stabilizing or improving the retinopathy.

Visual acuity should also be monitored to track any changes in vision and the effectiveness of interventions. It is essential to manage the underlying diabetes effectively to prevent further progression of retinopathy.

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Naxlex Comprehensive Predictor Exams

Exhibits Select the 3 dietary choices that are not part of the recommended diet for a client with gout.

Correct Answer is ["B","F","J"]

Explanation

Patient Data Exhibits 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.

Correct Answer is []

Explanation

Patient Data Exhibits The nurse has identified the priority problem for the client and now must determine proper care interventions. Based on the client history and the assessment data, what action(s) should the nurse anticipate? Select all that apply.

While caring for a client with a full thickness burn covering 40% of the body, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should review which of the client's laboratory values?

Patient Data Exhibits What order(s) should the nurse anticipate being prescribed after an update is reported to the healthcare providers? Select all that apply.

The nurse reviews discharge instructions with a client who has gastroesophageal reflux disease (GERD). Which instruction is most important for the nurse to emphasize?

The nurse is caring for a client who tests positive for the sexually transmitted infection (STI) gonorrhea. The client reports having sex with someone who has many partners. Which response should the nurse provide?

The healthcare provider prescribes penicillin 200,000 units IM for a client with pneumonia. The available vial is labeled, "Penicillin 500,000 units/mL. How many mL should the nurse administer to this client? (Enter numerical value only. If rounding is required, round to the nearest tenth.)