Question

A nurse is completing discharge instructions with a client following an acute onset of gout. Which of the following client statements indicates an understanding of the treatment regimen?

Answer 1

Correct Answers:

“I will limit my alcohol intake.”

Rationale :

🎗️ Alcohol raises uric acid production (adenosine breakdown), precipitating acute gout attacks.

🎗️ Beer/spirits impair renal urate excretion, worsening hyperuricemia and flares.

🎗️ Reducing alcohol lowers flare frequency alongside low-purine diet and hydration.

🎗️ Aspirin (esp. low dose) alters urate handling, so avoiding extra aspirin is prudent unless prescribed for other indications.

🎗️ Hydration should be increased (not restricted) to promote uric acid renal clearance.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 2

Correct Answers:

Minimize skin exposure to moisture
Use pillows to keep heels off the bed surface

Rationale :

🔷 Moisture-associated skin damage (incontinence/sweat) macerates skin → pressure injury risk.

🔷 Heel off-loading (“float the heels”) removes pressure over calcanei—common ulcer sites.

🔷 Repositioning q2h is the standard; q4h is too infrequent for prevention.

🔷 Avoid massaging erythema—microvascular damage can worsen tissue injury.

🔷 Powders can cake/irritate and do not replace moisture-barrier products.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 3

Correct Answers:

Manifestations preceded by a severe headache

Rationale :

🔶 “Worst headache of life” = classic for aneurysmal subarachnoid hemorrhage.

🔶 Abrupt onset with nuchal rigidity/photophobia frequently reported.

🔶 Loss of consciousness or vomiting may accompany rupture.

🔶 TIA-like deficits <1 hr fit ischemia/TIA, not hemorrhagic aneurysm.

🔶 Gradual onset suggests ischemic stroke or other etiologies, not rupture.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 4

Correct Answers

Blank 1 Correct Option: circulatory status
Blank 2 Correct Option: level of consciousness

Rationale :

💠 Airway/Breathing already supported (O₂ 2 L/min, SpO₂ 94%); next is Circulation.

💠 Signs of shock: faint pulses, clammy skin, low Hgb, oliguria (25 mL/hr) → perfusion issue.

💠 Treat circulation first (IV fluids/blood) per ABCDE trauma priorities.

💠 Disability/neurologic (LOC/GCS 7) is addressed after circulation per trauma algorithm.

💠 Early correction of hypovolemia improves cerebral perfusion and outcomes.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 5

Correct Answers:

Obtain a central venous pressure.

Rationale :

◆ Major burns (75%) → burn shock, massive fluid shifts; need preload trending.

◆ CVP guides resuscitation (e.g., Parkland + physiologic response), avoiding under/over-resuscitation.

◆ Noninvasive BP/pulse pressure won’t reflect intravascular volume accurately here.

◆ PA catheter is more invasive and not routine initially for burn resuscitation.

◆ Goal: maintain perfusion (UOP ≥0.5 mL/kg/hr adults) while watching CVP trends.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 6

Correct Answers:

Increased band neutrophils
Elevated erythrocyte sedimentation rate

Rationale :

🎀Bandemia = left shift, hallmark of acute bacterial infection.

🎀 ESR rises with inflammation/infection from increased fibrinogen.

🎀 Negative leukocyte esterase argues against UTI; not infection marker.

🎀 High hemoglobin does not indicate infection.

🎀Ketone absence is unrelated to infection in the postoperative setting.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 7

Correct Answers:

Absence of bowel sounds
Hypotension
Weakened gag reflex

Rationale :

💙 Spinal shock/ileus after cervical SCI → absent bowel sounds.

💙 Neurogenic shock (loss of sympathetic tone) → hypotension and bradycardia.

💙 Weakened gag risks aspiration; protect airway.

💙Thermoregulation impaired, but hyperthermia is not early-typical.

💙 Polyuria is not characteristic; urinary retention is more common acutely.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 8

Correct Answers:

The client is cooperative and oriented.

Rationale :

❖ Aldrete/modified discharge criteria prioritize orientation & airway protection.

❖ Purposeful, cooperative behavior shows adequate sedation recovery.

❖ Restlessness can signal hypoxia/pain—not ready.

❖ Only reacting to stimuli (brisk/sluggish) implies deeper sedation.

❖ Stable vitals + orientation = safe for discharge from recovery.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 9

Correct Answers:

Administer oxygen via nasal cannula.

Rationale :

✅ Immediate oxygen supports severe tachypnea (RR 40) and hypoperfusion.

✅ Do not remove the dressing on an open/sucking chest wound in triage—risk of air entrainment.

✅ Trendelenburg/raising foot 90° is unsafe and not indicated.

✅ Central line is not the priority; focus on oxygenation and preparing for occlusive dressing.

✅Definitive step (if option provided) is occlusive dressing taped on three sides plus high-flow O₂—oxygen is still the best available option here.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 10

Correct Answers

Blank 1 Correct Option: photosensitivity
Blank 2 Correct Option: chronic fatigue

Rationale :

✳️ SLE commonly causes photosensitivity (UV-triggered cutaneous flares).

✳️ Chronic fatigue is frequent from systemic inflammation/anemia.

✳️ Case data: butterfly rash, plaques, ↓Hgb, thrombocytopenia, ↑ESR support active SLE.

✳️ Weight loss can occur, but photosensitivity/fatigue are more defining risks.

✳️ Hypoglycemia is not a typical SLE risk from the scenario provided.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

QLexNursing

1 :
A nurse is completing discharge instructions with a client following an acute onset of gout. Which of the following client statements indicates an understanding of the treatment regimen?

2 :
A nurse is developing a plan of care to prevent skin breakdown for a client with a spinal cord injury and paralysis. Which of the following nursing actions are appropriate? (Select All that Apply.)

3 :
A nurse is caring for a client who has had a hemorrhagic stroke following a ruptured cerebral aneurysm. Which of the following manifestations should the nurse expect?

4 :
A nurse is caring for a client who was involved in a motor-vehicle crash.

Correct Answers

5 :
A nurse is caring for a client who has full-thickness burns over 75% of his body. The nurse should use which of the following methods to monitor the cardiovascular system?

6 :
A nurse is reviewing the laboratory results of a client who is postoperative. Which of the following laboratory findings should the nurse identify as an indication of a postoperative infection? (Select All that Apply.)

7 :
A nurse in the emergency department is monitoring a client who has a cervical spinal cord injury from a fall. The nurse should monitor the client for which of the following complications? (Select All that Apply.)

8 :
A nurse is assessing a client who received IV conscious sedation for a colonoscopy. Which of the following findings indicated that the client is ready for discharge?

9 :
A nurse in an emergency department is caring for a client who has a sucking chest wound resulting from a gunshot. The client has a blood pressure of 100/60 mm Hg a weak pulse rate of 118/min. and a respiratory rate of 40/min. Which of the following actions should the nurse take?

10 :
A nurse in a clinic is caring for a client who has a new diagnosis of systemic lupus erythematosus (SIE).

Correct Answers

QLexNursing

1 : A nurse is completing discharge instructions with a client following an acute onset of gout. Which of the following client statements indicates an understanding of the treatment regimen?

2 : A nurse is developing a plan of care to prevent skin breakdown for a client with a spinal cord injury and paralysis. Which of the following nursing actions are appropriate? (Select All that Apply.)

3 : A nurse is caring for a client who has had a hemorrhagic stroke following a ruptured cerebral aneurysm. Which of the following manifestations should the nurse expect?

4 : A nurse is caring for a client who was involved in a motor-vehicle crash.

Correct Answers

5 : A nurse is caring for a client who has full-thickness burns over 75% of his body. The nurse should use which of the following methods to monitor the cardiovascular system?

6 : A nurse is reviewing the laboratory results of a client who is postoperative. Which of the following laboratory findings should the nurse identify as an indication of a postoperative infection? (Select All that Apply.)

7 : A nurse in the emergency department is monitoring a client who has a cervical spinal cord injury from a fall. The nurse should monitor the client for which of the following complications? (Select All that Apply.)

8 : A nurse is assessing a client who received IV conscious sedation for a colonoscopy. Which of the following findings indicated that the client is ready for discharge?

9 : A nurse in an emergency department is caring for a client who has a sucking chest wound resulting from a gunshot. The client has a blood pressure of 100/60 mm Hg a weak pulse rate of 118/min. and a respiratory rate of 40/min. Which of the following actions should the nurse take?

10 : A nurse in a clinic is caring for a client who has a new diagnosis of systemic lupus erythematosus (SIE).

Correct Answers

1 :
A nurse is completing discharge instructions with a client following an acute onset of gout. Which of the following client statements indicates an understanding of the treatment regimen?

2 :
A nurse is developing a plan of care to prevent skin breakdown for a client with a spinal cord injury and paralysis. Which of the following nursing actions are appropriate? (Select All that Apply.)

3 :
A nurse is caring for a client who has had a hemorrhagic stroke following a ruptured cerebral aneurysm. Which of the following manifestations should the nurse expect?

4 :
A nurse is caring for a client who was involved in a motor-vehicle crash.

5 :
A nurse is caring for a client who has full-thickness burns over 75% of his body. The nurse should use which of the following methods to monitor the cardiovascular system?

6 :
A nurse is reviewing the laboratory results of a client who is postoperative. Which of the following laboratory findings should the nurse identify as an indication of a postoperative infection? (Select All that Apply.)

7 :
A nurse in the emergency department is monitoring a client who has a cervical spinal cord injury from a fall. The nurse should monitor the client for which of the following complications? (Select All that Apply.)

8 :
A nurse is assessing a client who received IV conscious sedation for a colonoscopy. Which of the following findings indicated that the client is ready for discharge?

9 :
A nurse in an emergency department is caring for a client who has a sucking chest wound resulting from a gunshot. The client has a blood pressure of 100/60 mm Hg a weak pulse rate of 118/min. and a respiratory rate of 40/min. Which of the following actions should the nurse take?

10 :
A nurse in a clinic is caring for a client who has a new diagnosis of systemic lupus erythematosus (SIE).