Nokea
The nurse is caring for a 5-year-old client with sickle cell disease who is experiencing an episode of acute pain. The client has shortness of breath, nausea with vomiting, and severe generalized body and joint pain. Which of the following findings requires immediate intervention?
- A. enlarged spleen on palpation
- B. hemoglobin level of 9.0 g/dL (90 g/L)
- C. bilateral swelling of the hands and feet
- D. pain rated as 8 on the Wong-Baker FACES Scale
Correct Answer: A
Rationale: An enlarged spleen may indicate splenic sequestration, a life-threatening complication requiring immediate intervention.
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The nurse is reinforcing teaching to a client diagnosed with Raynaud phenomenon about ways to prevent recurrent episodes. Which instructions should the nurse include? Select all that apply.
- A. Avoid excess caffeine
- B. Immerse hands in cold water
- C. Practice yoga or tai chi
- D. Refrain from using tobacco products
- E. Wear gloves when handling cold objects
Correct Answer: A,C,D,E
Rationale: Caffeine, tobacco, and cold exposure can trigger Raynaud episodes. Yoga/tai chi and gloves help prevent attacks. Cold water immersion exacerbates symptoms.
Which measures will help prevent falls in the elderly clients of a long-term care facility? Select all that apply.
- A. Exercise programs
- B. Good room lighting
- C. Handrails in stairwell
- D. Smooth-soled shoes
- E. Staff hourly rounds
Correct Answer: A,B,C,E
Rationale: Exercise, lighting, handrails, and rounds reduce fall risk. Smooth-soled shoes increase slipping risk.
The nurse is caring for a newborn with jaundice who is being treated with phototherapy. What action by the nurse would require the charge nurse to intervene?
- A. Allowing the parents to feed the newborn
- B. Applying a shirt while the client is exposed to phototherapy
- C. Covering the client's eyes with protective shields
- D. Monitoring the temperature of the incubator while the newborn is inside
Correct Answer: B
Rationale: Clothing during phototherapy reduces skin exposure to light, decreasing treatment efficacy.
A client with a history of renal calculi passes a stone made up of calcium oxalate. Which of the following diet instructions should be given to the client?
- A. Increase intake of meats, eggs, fish, plums, and cranberries.
- B. Avoid citrus fruits and juices.
- C. Avoid dark green, leafy vegetables.
- D. Increase intake of dairy products.
Correct Answer: C
Rationale: Dark green, leafy vegetables are high in oxalates, which contribute to calcium oxalate stones. Meats and dairy increase other stone types, and citrus juices are beneficial.
Which of the following is not considered one of the five rights of medication administration?
- A. client
- B. drug
- C. dose
- D. routine
Correct Answer: D
Rationale: Dose, client, drug, route and time are considered the five rights of medication.