A client is in the emergency room in critical condition and hypotensive. Her spouse is distraught. What is the priority nursing action?

Correct Answer: A

Rationale: In this scenario, the priority nursing action is to maintain the client's blood pressure (Option A). This is because the client is in critical condition and hypotensive, indicating a life-threatening situation that requires immediate intervention to stabilize their condition and prevent further deterioration. Ensuring the client's hemodynamic stability takes precedence in this emergency situation to improve their chances of survival. Calling a chaplain (Option B) may be important for emotional and spiritual support but is not the immediate priority when the client's physiological needs are not met. Providing the spouse a chair (Option C) is a compassionate gesture but does not address the critical medical needs of the client. Asking the client's spouse to explain what happened (Option D) is not the priority at this moment as the focus should be on providing urgent medical care. From an educational perspective, this question emphasizes the importance of prioritizing nursing actions based on the client's condition and the urgency of the situation. It highlights the need for quick decision-making and critical thinking in emergency care scenarios to provide safe and effective patient care. Nurses must be able to rapidly assess and prioritize interventions to address life-threatening conditions and stabilize the client's health.

Correct Answer: B

Rationale: In the context of managing gout through a low-purine diet, option B, "I should avoid eating liver and other organ meats," is the correct choice. Organ meats like liver are high in purines, which can lead to increased uric acid levels and worsen gout symptoms. By avoiding organ meats, the client can better control their purine intake, thereby reducing the risk of gout flare-ups. Option A, "I should choose red meat instead of poultry," is incorrect as both red meat and poultry can be high in purines. Red meat, in general, should be limited in a low-purine diet. Option C, "I can drink only white wine," is incorrect as alcohol, in general, should be consumed in moderation or avoided, particularly beer and spirits which are high in purines. White wine still contains purines and should not be the focus of dietary changes for gout management. Option D, "I will need to limit the number of fruit servings each day," is incorrect as most fruits are low in purines and are generally considered safe for individuals with gout. It is important to focus more on limiting high-purine foods like organ meats and certain seafood rather than fruits when following a low-purine diet for gout. Educationally, this question highlights the importance of understanding the specific dietary recommendations for managing conditions like gout. It emphasizes the need for clients to be aware of which foods to avoid or limit to effectively control their symptoms and improve their overall health.

Correct Answer: A

Rationale: In this scenario, Option A is the correct answer because it provides essential information regarding the adverse effects associated with nonsteroidal anti-inflammatory drugs (NSAIDs), which are commonly prescribed for conditions like osteomyelitis. Liver failure and tinnitus are significant adverse effects of NSAIDs that the nurse should educate the client about to ensure proper medication management and monitoring. Option B is incorrect as it refers to acetaminophen, not NSAIDs, and gastrointestinal bleeding is not the main side effect of acetaminophen. Option C is partially correct as it highlights the maximum daily dose of acetaminophen, but it does not address the specific teaching related to NSAIDs for osteomyelitis. Option D is incorrect as NSAIDs do have potential side effects, and it is essential for the nurse to educate the client about these risks. From an educational perspective, understanding the potential adverse effects of medications is crucial for nurses to provide comprehensive care and ensure patient safety. By explaining the specific risks associated with NSAIDs in the context of osteomyelitis treatment, nurses can empower patients to make informed decisions about their health and medication management.

Correct Answer: D

Rationale: In a client with rheumatoid arthritis one day after shoulder surgery, paresthesia in the fingers and intense increasing pain in the shoulder could indicate nerve compression or damage, which are serious post-operative complications. This situation requires immediate attention from the provider to prevent further complications and ensure appropriate management. The other options, such as refusing pain medication, reporting a minor headache, or experiencing minor abdominal discomfort, are important but not as urgent or indicative of potential serious complications as paresthesia in the fingers and intense increasing pain in the shoulder.

Correct Answer: C

Rationale: In the case of a client with systemic lupus erythematous (SLE) experiencing flank pain, the nurse would anticipate that a creatinine test will be ordered. This is because flank pain in a patient with SLE could be indicative of lupus nephritis, a common and serious complication where the kidneys are affected. Creatinine levels are a key indicator of kidney function, and an elevated creatinine level would suggest impaired kidney function, which is crucial information for managing a patient with lupus nephritis. Option A) Platelets: Platelet levels are not typically associated with flank pain in SLE. Platelets are more relevant in conditions like thrombocytopenia, which is a common hematologic manifestation of SLE. Option B) Skin biopsy: Skin biopsy is not directly related to flank pain in SLE. It is a diagnostic procedure used to evaluate skin conditions, not kidney involvement. Option D) Hemoglobin: Hemoglobin levels are important in assessing for anemia, which can be a complication of SLE, but they are not the primary concern when a patient presents with flank pain indicative of possible kidney involvement. Educationally, understanding the rationale behind ordering specific laboratory tests in the context of different symptoms and conditions is crucial for nurses to provide comprehensive care. Connecting clinical manifestations with appropriate diagnostic tests enhances nurses' ability to recognize and respond to potential complications promptly, thereby improving patient outcomes.