Question 5241)
The client is a 64-year-old male admitted to the hospital with severe pain in his
right big toe, which is red and swollen. Which nursing care measure is most essential for the nurse
to perform at this time?
A. Use a bed cradle on the bed
B. Put a bed board on the bed
C. Obtain a heat lamp
D. Prepare to catheterize the client
Answer: A
Explanation: The pain of gout is very severe. A bed cradle will keep the bed linens off his toe. There is no
indication for a bed board. Bed boards are indicated for back problems. A heat lamp is not part of the therapy for
gout. There is no indication of a need to catheterize the client.
Question 5242)
The nurse is to give the client with gout one tablet of colchicine every hour until
relief or toxicity occurs. Which of the following is an indication for stopping the colchicine?
A. Ringing in the ears
B. Nausea and vomiting
C. A rash on the client’s hips
D. A temperature of 101°F
Answer: B
Explanation: Nausea, vomiting, and diarrhea indicate toxicity to colchicine. Tinnitus indicates aspirin toxicity. Rash
and fever are not usual signs of colchicine toxicity.
Question 5243) The nurse is teaching the client with gout about a diet low in purines. Which of
the following is lowest in purine?
A. Roast chicken
B. Beef liver
C. Fried shrimp
D. Scrambled eggs
Answer: D
Explanation: Eggs are lowest in purine. Chicken, organ meats such as liver, and shrimp are high in purines.
Question 5244)
The client is now over an acute episode of gout. He is to be discharged on
allopurinol (Zyloprim). What instruction must the nurse give to this client?
A. “Take your medicine on an empty stomach.”
B. “Report any nausea to your physician at once.”
C. “Drink two to three quarts of fluids daily.”
D. “Do not take over-the-counter cold medicine.”
Answer: C
Explanation: It is essential to force fluids when taking allopurinol, a uricosuric drug. This will help the uric acid
crystals to be excreted in the urine and not collect in the kidneys and form stones. The medicine does not need to
be taken on an empty stomach. Nausea can be a side effect of the allopurinol. However, the priority instruction is
to drink large amounts of fluid. There is no contraindication with over-the-counter cold medicine.
Question 5245)
The client with arthritis is receiving sodium salicylate and asks the nurse what the
drug will do for her. The nurse’s reply should include information that the drug is given for which
of the following effects?
A. Antipyretic
B. Antibiotic
C. Anticoagulant
D. Anti-inflammatory
Answer: D
Explanation: Sodium salicylate has all of the effects except antibiotic. However, it is given to a person with arthritis
primarily for its anti-inflammatory effect. The anticoagulant action can be an adverse effect for this client.
Question 5246)
The client with newly diagnosed rheumatoid arthritis asks what can happen if no
treatment is done. The nurse knows that if rheumatoid arthritis is left untreated, which of the
following would be most apt to develop?
A. Bony ankylosis
B. Chronic osteomyelitis
C. Pathological fractures
D. Joint hypermobility
Answer: A
Explanation: Bony ankylosis occurs in untreated rheumatoid arthritis. Osteomyelitis is a bone infection and is not
related to rheumatoid arthritis. Pathological Fractures are result of severe osteoporosis, not arthritis. Joints lose
mobility and become ankylosed; they do not have hypermobility.
Question 5247)
The client with rheumatoid arthritis is to receive prednisone 2.5 mg P.O. before
meals and at bedtime. What is the primary expected action of the drug?
A. Maintenance of sodium and potassium balance
B. Improvement of carbohydrate metabolism
C. Production of androgen-like effects
D. Interference with inflammatory reactions
Answer: D
Explanation: Prednisone is a corticosteroid and has an anti-inflammatory effect. It does affect sodium and potassium
balance and carbohydrate metabolism and causes androgen-like effects; however, these are seen as bothersome
side effects when given to a client who has arthritis.
Question 5248)
The client is admitted to the hospital for a diagnostic workup. The client has vague
symptoms of malaise, coughing, chest discomfort, low-grade fever, diffuse rashes, and
musculoskeletal aches and pains. A diagnosis of probable lupus erythematosus has been made. The
night nurse finds the client crying and saying, “I would rather die than suffer with this disease for
the rest of my life.” Which response by the nurse would be most therapeutic at this time?
A. Telling the client there are support groups to join after discharge
B. Offering to stay with the client to discuss concerns and questions
C. Advising the client to write concerns on paper to discuss with the doctors and nurses tomorrow
D. Offering the client a back rub and a warm cup of milk
Answer: B
Explanation: Offering help and letting the client express feelings is most therapeutic at this time. Telling the client
about support groups may be appropriate later. Advising the client to write her concerns on paper to discuss
tomorrow could be appropriate after the nurse had listened to the client’s concerns and feelings. At this time, that
response closes communication. Giving the client a back rub and a warm cup of milk could be done after listening
to the client.
Question 5249)
The elderly client having diabetes and peripheral vascular disease for several
years. He now has had a right below-the-knee amputation. Which preoperative nursing action will
do the most to help the client adjust to having an amputation?
A. Encouraging deep breathing
B. Asking him if he understands the full effects of the planned surgery
C. Discussing the effects of diabetes on the vascular system
D. Having a recovered amputee visit him
Answer: D
Explanation: Seeing an amputee who is living successfully will do the most to help him adjust to having an
amputation. All of the others might be done but do not help him to adjust to an amputation.
Question 5250)
The client has returned to the nursing unit following a right below-the-knee
amputation. How should the nurse position the client?
A. Supine with head turned to the side
B. With shock blocks placed under the foot of the bed
C. Semi-sitting position with knees bent
D. Left lateral with pillows between the knees
Answer: B
Explanation: The foot of the bed should be raised to prevent edema formation in the stump. Shock blocks are the
best way to accomplish this. Pillows can be used for the first 24 to 28 hours only. Note that the client has returned
to the nursing unit. The client will be awake before returning to the nursing unit, so turning the head to the side is
not needed. Positioning the client in a semi-sitting position with knees bent would cause swelling of the surgical
site and is contraindicated. Positioning the client on the side with pillows between the knees is not the most
appropriate position.
Question 5251)
The day after an amputation, the client begins to hemorrhage from his stump.
What action should the nurse take first?
A. Apply a pressure dressing to the stump
B. Place a tourniquet above the stump
C. Notify the physician
D. Apply an ice pack to the stump
Answer: B
Explanation: Applying a tourniquet is the best action because the bleeders are usually too large to be controlled by
pressure. This is one of the very few times when applying a tourniquet is indicated. An ice pack will be ineffective
in controlling hemorrhage from the stump. The nurse should notify the physician but should attempt to stop the
bleeding before leaving the client to call the physician
Question 5252)
The client continues to recover following a below-the-knee amputation. What
nursing action should the nurse employ to help prevent the most common complication following
leg amputation?
A. Clean the wound with hydrogen peroxide three times a day
B. Have the client lie prone several times a day
C. Ask the client to flex and extend the toes on the remaining leg
D. Encourage the client to completely empty his/ her bladder
Answer: B
Explanation: The most common complication is flexion contracture of the hip or knee. Having the client lie prone
will help to prevent flexion contractures of the hip and knee. The wound should be kept clean, but not usually
with hydrogen peroxide three times a day. Asking the client to flex and extend the toes on the remaining leg will
help to prevent thrombophlebitis in the remaining leg and is certainly appropriate. However, thrombophlebitis is
not the most common complication following leg amputation. It is appropriate to encourage the client to empty the
bladder. However, a bladder infection is not the most common complication following leg amputation.
Question 5253)
A young adult is discharged to home with crutches. Which exercise should the
nurse teach the client in order to strengthen the hand muscles for crutch walking?
A. Pushing the buttocks up off the mattress
B. Pulling the body up, using an overhead trapeze
C. Raising the legs straight up and down
D. Squeezing a rubber ball in each hand
Answer: D
Explanation: Squeezing a rubber ball strengthens finger flexors. Pull-ups strengthen the biceps muscles. Straight leg
raises strengthen the hip flexor and quadriceps.
Question 5254)
The client is ordered to be in a semi-reclining position following a myelogram. The
nurse understands that the primary reason for this is which of the following?
A. To prevent infection
B. To prevent spinal headache
C. To prevent seizures
D. To promote excretion of dye
Answer: C
Explanation: When a client is ordered to be semi-reclining following a myelogram, the nurse knows the physician
used a water-based dye. The reason for the semi-reclining position is to prevent development of seizures. With a
water-based dye, fluids are encouraged to promote excretion of the dye. Positioning does not prevent
development of infection.
Question 5255)
The client has a fractured right ankle that has just been casted. The nurse is
instructing the client in crutch walking techniques. Which method is most appropriate?
A. Move the right crutch, then the left foot, then the left crutch, and finally the right foot.
B. Balance weight on the left foot and move right foot and both crutches forward, then bear weight on both crutches
and move the left foot forward.
C. Move the right crutch and left foot forward together; then move the left crutch and right foot.
D. Move the right crutch and right foot together; then move the left crutch and the left foot.
Answer: B
Explanation: A three-point gait is indicated when the client can bear no weight on one foot. This correctly describes
a three-point gait for someone with a right foot problem. Answer 1 describes a fourpoint gait. The client must be
able to bear weight on both feet for this gait. Answer 3 correctly describes a two-point gait. The client must be
able to bear weight on both feet for this gait. Answer 4 does not correctly describe any gait.
Question 5256)
What should be included in the nursing care plan for a client with diabetes
insipidus?
A. Blood pressure every hour
B. Strict intake and output
C. Urine for ketone bodies
D. Glucose monitoring four times a day
Answer: B
Explanation: Diabetes insipidus is excessive urine output due to decreased amounts of antidiuretic hormone.
Because of the excessive urine output, it is necessary to monitor intake and output.
Question 5257)
What must the nurse do when preparing a client for a computed tomography (CT)
scan?
A. Administer a laxative prep
B. Encourage fluids
C. Explain the procedure
D. Administer a radioisotope
Answer: C
Explanation: Explanation is all that is necessary. The client is not given a radioisotope. Fluids are not pushed prior
to the procedure. The client frequently is given an iodine dye, so the nurse should ask about allergies to shellfish.
Question 5258)
Antibiotics are ordered for a client who has had a transsphenoidal
hypophysectomy. He asks why he is receiving an antibiotic when he does not have an infection.
The primary reason for administering antibiotics to this client is based on which information?
A. Antibiotics will help to prevent respiratory complications following surgery.
B. Meningitis is a complication following transsphenoidal hypophysectomy.
C. Fluid retention can cause dangerously high cerebro spinal fluid pressure.
D. Hormone replacement is essential after hypophysectomy
Answer: B
Explanation: A transsphenoidal approach goes through the roof of the mouth, which has many organisms. Meningitis
can occur. Answer 1 is a true statement but not the primary reason in this case. Antibiotics do not lower spinal
fluid pressure. Answer 4 is a true statement, but antibiotics are not hormones.
Question 5259)
Twelve hours after a transsphenoidal hypophysectomy, the client keeps clearing
his throat and complains of a drip in his mouth. To accurately assess this, the nurse should test
the fluid for:
A. sugar.
B. protein.
C. bacteria.
D. blood.
Answer: A
Explanation: Dripping in the back of the throat after a transsphenoidal hypophysectomy may be cerebrospinal fluid
(CSF). CSF contains glucose. Saliva and mucus do not.
Question 5260)
The client is ready for discharge following an adrenalectomy. Which statement
that the client makes indicates the best understanding of the client’s condition?
A. “I will continue on a low-sodium, lowpotassium diet.”
B. “My husband has arranged for a marriage counselor because of our fights.”
C. “I will stay out of the sun so I will not turn splotchy brown.”
D. “I will take all of those pills every day.”
Answer: D
Explanation: The client must take steroid replacements every day for the rest of his/her life. Answer 1 is not an
appropriate diet. The client should be on a highsodium, low-potassium diet. The fights should decrease as mood
swings decrease after surgery. The medications do not cause photosensitivity.
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