Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A home health nurse reinforces instructions to a client who is taking allopurinol for the treatment of gout. The nurse provides which client instructions?
A. Place an ice pack on the lips if they swell.
Reason: Placing an ice pack on the lips if they swell is not an appropriate instruction for a client who is taking allopurinol, as it may indicate an allergic reaction or angioedema, which requires immediate medical attention.
B. Use an over-the-counter (OTC) antihistamine lotion if a rash develops.
Reason: Using an OTC antihistamine lotion if a rash develops is not an appropriate instruction for a client who is taking allopurinol, as it may indicate a serious skin reaction such as Stevens-Johnson syndrome or toxic epidermal necrolysis, which requires immediate medical attention.
C. Drink at least 8 glasses of fluid every day.
Reason: Drinking at least 8 glasses of fluid every day is an appropriate instruction for a client who is taking allopurinol, as it helps to prevent kidney stones and flush out uric acid from the body.
D. Take the medication on an empty stomach 2 hours before meals.
Reason: Taking the medication on an empty stomach 2 hours before meals is not an appropriate instruction for a client who is taking allopurinol, as it may cause stomach upset or nausea. The medication should be taken after meals with plenty of water.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Med Surg Proctored Exam 3. Take the full exam now
Full Explanation
Choice A Reason: Placing an ice pack on the lips if they swell is not an appropriate instruction for a client who is taking allopurinol, as it may indicate an allergic reaction or angioedema, which requires immediate medical attention.
Choice B Reason: Using an OTC antihistamine lotion if a rash develops is not an appropriate instruction for a client who is taking allopurinol, as it may indicate a serious skin reaction such as Stevens-Johnson syndrome or toxic epidermal necrolysis, which requires immediate medical attention.
Choice C Reason: Drinking at least 8 glasses of fluid every day is an appropriate instruction for a client who is taking allopurinol, as it helps to prevent kidney stones and flush out uric acid from the body.
Choice D Reason: Taking the medication on an empty stomach 2 hours before meals is not an appropriate instruction for a client who is taking allopurinol, as it may cause stomach upset or nausea. The medication should be taken after meals with plenty of water.
Similar Questions
A client with a fracture of the left arm that has been set in a cast complains of severe, diffuse pain that is unrelieved by pain medication. The nurse notes that the pulse distal to the site of injury has weakened and that the tissue is pale. Which of the following nursing actions should the nurse perform first?
A. Contact the health care provider.
Reason: Contacting the health care provider is the first nursing action that the nurse should perform, as it indicates that the client may have compartment syndrome, which is a medical emergency that requires immediate intervention to prevent tissue necrosis and nerve damage.
B. Administer PRN pain medication.
Reason: Administering PRN pain medication is not the first nursing action that the nurse should perform, as it may not relieve the pain and may mask the symptoms of compartment syndrome.
C. Document the findings.
Reason: Documenting the findings is not the first nursing action that the nurse should perform, as it may delay the treatment and worsen the outcome of compartment syndrome.
D. Elevate the extremity.
Reason: Elevating the extremity is not the first nursing action that the nurse should perform, as it may decrease blood flow and increase tissue ischemia in compartment syndrome.
Full Explanation
Choice A Reason: Contacting the health care provider is the first nursing action that the nurse should perform, as it indicates that the client may have compartment syndrome, which is a medical emergency that requires immediate intervention to prevent tissue necrosis and nerve damage.
Choice B Reason: Administering PRN pain medication is not the first nursing action that the nurse should perform, as it may not relieve the pain and may mask the symptoms of compartment syndrome.
Choice C Reason: Documenting the findings is not the first nursing action that the nurse should perform, as it may delay the treatment and worsen the outcome of compartment syndrome.
Choice D Reason: Elevating the extremity is not the first nursing action that the nurse should perform, as it may decrease blood flow and increase tissue ischemia in compartment syndrome.
A nurse is contributing to the plan of care for a client who has urolithiasis. Which of the following interventions should the nurse include in the plan?
A. Tell the client to expect a decrease in urine output.
Reason: Telling the client to expect a decrease in urine output is not an appropriate intervention for a client who has urolithiasis, as it may indicate dehydration, obstruction, or infection.
B. Encourage the client to drink 3 L of fluids per day.
Reason: Encouraging the client to drink 3 L of fluids per day is an appropriate intervention for a client who has urolithiasis, as it helps to flush out stones, prevent new stone formation, and reduce urinary concentration.
C. Provide the client with a high protein diet.
Reason: Providing the client with a high protein diet is not an appropriate intervention for a client who has urolithiasis, as it may increase uric acid and calcium excretion and promote stone formation.
D. Maintain the client on bed rest.
Reason: Maintaining the client on bed rest is not an appropriate intervention for a client who has urolithiasis, as it may decrease renal perfusion and increase urinary stasis.
Full Explanation
Choice A Reason: Telling the client to expect a decrease in urine output is not an appropriate intervention for a client who has urolithiasis, as it may indicate dehydration, obstruction, or infection.
Choice B Reason: Encouraging the client to drink 3 L of fluids per day is an appropriate intervention for a client who has urolithiasis, as it helps to flush out stones, prevent new stone formation, and reduce urinary concentration.
Choice C Reason: Providing the client with a high protein diet is not an appropriate intervention for a client who has urolithiasis, as it may increase uric acid and calcium excretion and promote stone formation.
Choice D Reason: Maintaining the client on bed rest is not an appropriate intervention for a client who has urolithiasis, as it may decrease renal perfusion and increase urinary stasis.
When evaluating a client how to administer insulin, which action indicates that additional teaching is necessary?
A. Checks blood sugar then eats breakfast prior to injecting insulin.
Reason: Checking blood sugar then eating breakfast prior to injecting insulin indicates that additional teaching is necessary, as it may cause hyperglycemia or hypoglycemia depending on the type and timing of insulin. The client should inject insulin before eating breakfast according to their blood sugar level and carbohydrate intake.
B. Rotates sites from arms, legs, and abdomen.
Reason: Rotating sites from arms, legs, and abdomen indicates that no additional teaching is necessary, as it helps to prevent lipodystrophy and ensure consistent absorption of insulin.
C. Ensures the use of insulin syringe with units.
Reason: Ensuring the use of insulin syringe with units indicates that no additional teaching is necessary, as it helps to prevent dosing errors and ensure accurate administration of insulin.
D. Activates the safety lock on the syringe before disposing in a sharps container.
Reason: Activating the safety lock on the syringe before disposing in a sharps container indicates that no additional teaching is necessary, as it helps to prevent needlestick injuries and infection transmission.
Full Explanation
Choice A Reason: Checking blood sugar then eating breakfast prior to injecting insulin indicates that additional teaching is necessary, as it may cause hyperglycemia or hypoglycemia depending on the type and timing of insulin. The client should inject insulin before eating breakfast according to their blood sugar level and carbohydrate intake.
Choice B Reason: Rotating sites from arms, legs, and abdomen indicates that no additional teaching is necessary, as it helps to prevent lipodystrophy and ensure consistent absorption of insulin.
Choice C Reason: Ensuring the use of insulin syringe with units indicates that no additional teaching is necessary, as it helps to prevent dosing errors and ensure accurate administration of insulin.
Choice D Reason: Activating the safety lock on the syringe before disposing in a sharps container indicates that no additional teaching is necessary, as it helps to prevent needlestick injuries and infection transmission.