Nokea
A 24-year-old male client is admitted with a diagnosis of sickle cell anemia. The nurse discusses his disease with him and emphasizes the following information:
- A. He should monitor his sputum, stools, and urine for signs of bleeding.
- B. His daily diet should include a large amount of fluid.
- C. He should not be concerned about having to fly on a commuter airplane on a weekly basis.
- D. He should not worry about having children because this disease is passed on only by female carriers.
Correct Answer: B
Rationale: Bleeding is not a symptom of sickle cell anemia or sickle cell crisis. Decreased blood viscosity leads to sickling of red blood cells. Increased fluid intake maintains adequate circulating blood volume and decreases the chance of sickling. Hypoxia leads to sickling of cells. Flying in nonpressurized planes places the client in a situation of low O2 tension, which can lead to sickling. Male and female clients with sickle cell disease can pass the trait on to their offspring. Therefore, this client should receive genetic counseling prior to having children.
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A client has been admitted to the nursing unit with the diagnosis of severe anemia. She is slightly short of breath, has episodes of dizziness, and complains her heart sometimes feels like it will 'beat out of her chest.' The physician has ordered her to receive 2 U of packed red blood cells. The most important nursing action to be taken is:
- A. Starting an 18-gauge IV infusion
- B. Having the consent form on the chart
- C. Administering the correct blood product to the correct client
- D. Transfusing the blood in a 2-hour time frame
Correct Answer: C
Rationale: An 18-gauge IV is an appropriate size for administering blood; however, client safety demands that the right blood product must be administered. The consent form is legally necessary to be on the chart, but client safety is maintained by giving the correct blood component to the correct client. Administering the correct blood product to the correct client will maintain physiological safety and minimize transfusion reactions. The blood administration should take place over the ordered time frame designated by the physician.
The registered nurse is making assignments for the day. Which client should be assigned to the nurse who is pregnant?
- A. The client with HIV treated with Pentam (pentamidine)
- B. The client with cervical cancer treated with a radium implant
- C. The client with RSV treated with Virazole (ribavirin)
- D. The client with cytomegalovirus treated with Valcyte (valganciclovir)
Correct Answer: D
Rationale: Valganciclovir for cytomegalovirus poses minimal risk to a pregnant nurse as it is not teratogenic and standard precautions suffice. Pentamidine ribavirin and radium implants carry higher risks due to potential teratogenicity or radiation exposure.
The nurse is caring for a client with a history of Raynaud’s disease. The nurse should expect the client to have:
- A. Color changes in fingers
- B. Joint swelling
- C. Fever
- D. Chest pain
Correct Answer: A
Rationale: Raynaud’s disease causes vasospasms, leading to color changes (white, blue, red) in the fingers triggered by cold or stress.
A child with celiac disease is being discharged from the hospital. The mother demonstrates knowledge of nutritional needs of her child when she is able to state the foods which are included in a:
- A. Lactose-restricted diet
- B. Gluten-restricted diet
- C. Phenylalanine-restricted diet
- D. Fat-restricted diet
Correct Answer: B
Rationale: A lactose-restricted diet is prescribed for children with lactose intolerance or diarrhea. A gluten-restricted diet is the diet for children with celiac disease. A phenylalanine-restricted diet is prescribed for children with phenylketonuria. A fat-restricted diet is prescribed for children with disorders of the liver, gallbladder, or pancreas.
The doctor has ordered a restricted fluid intake for a 2-year-old child with a head injury. Normal fluid intake for a child of 2 years is:
- A. 900 mL/24 hr
- B. 1300 mL/24 hr
- C. 1600 mL/24 hr
- D. 2000 mL/24 hr
Correct Answer: C
Rationale: Normal intake for a child of 2 years is about 1600 mL in 24 hours.