Nokea
A 35 year-old client with sickle cell crisis is talking on the telephone but stops as the nurse enters the room to request something for pain. The nurse should
- A. Administer a placebo
- B. Encourage increased fluid intake
- C. Administer the prescribed analgesia
- D. Recommend relaxation exercises for pain control
Correct Answer: C
Rationale: Administer the prescribed analgesia. Pain relief is a priority in sickle cell crisis, and prescribed analgesics are appropriate.
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The nurse is caring for a client with a vascular access for hemodialysis. Which of these findings necessitates immediate action by the nurse?
- A. pruritic rash
- B. dry, hacking cough
- C. chronic fatigue
- D. elevated temperature
Correct Answer: D
Rationale: It is a priority to report this finding since clients on hemodialysis are prone to infection, and the first sign is an elevated temperature.
The unlicensed assistive personnel notifies the charge nurse that the client is reporting feeling short of breath. What should the charge nurse do first?
- A. Activate a rapid response team
- B. Ask the unlicensed assistive personnel to take vital signs and report back
- C. Direct the client's primary nurse to examine the client
- D. Personally go and auscultate the client's lungs
Correct Answer: C
Rationale: Directing the primary nurse to assess the client ensures a timely, qualified evaluation of shortness of breath, a potentially serious symptom.
Vital signs
Temperature 98.2 F (36.7 C)
Blood pressure 108/72 mm Hg
Heart rate 62/min
Respirations 16/min
SpO2 96% on room air
A client who developed heart failure after a myocardial infarction is scheduled to be discharged this afternoon. Based on the discharge data, the nurse plans to reinforce which home care instructions? Select all that apply.
- A. How to take own pulse
- B. Monitoring daily weight
- C. Need for monthly International Normalized Ratio testing
- D. Need to increase foods high in potassium
- E. Reduction of sodium in diet
- F. Use of home oxygen
Correct Answer: A,B,E
Rationale: Taking pulse (A), monitoring weight (B), and reducing sodium (E) help manage heart failure by tracking symptoms, detecting fluid retention, and preventing exacerbation.
Laboratory reference ranges
Glucose (random)
71-200 mg/dL
(3.9–11.1 mmol/L)
The nurse is caring for assigned clients. Which of the following clients should the nurse check first?
- A. client who had a cholecystectomy and is reporting incisional pain as 5 on a scale of 1-10
- B. client who had an open reduction of the right femur and is reporting nausea
- C. client with type 1 diabetes mellitus and a blood glucose level of 55 mg/dL (3.1 mmol/L)
- D. client with type 2 diabetes mellitus and a blood glucose level of 250 mg/dL (13.9 mmol/L)
Correct Answer: C
Rationale: A blood glucose level of 55 mg/dL indicates severe hypoglycemia, a life-threatening condition requiring immediate intervention to prevent seizures or coma.
A new mother is two days postpartum, is breastfeeding her infant, and now is preparing for discharge. She states that for contraception she is going to use her diaphragm, which she still has. The nurse's response should be based on which information?
- A. Diaphragms need to be refitted after the birth of a baby.
- B. As long as the diaphragm is in good shape, the client can continue to use it.
- C. Diaphragms are not good contraceptives for postpartal women.
- D. Since the client is breastfeeding, she will not need her diaphragm for four to six months.
Correct Answer: A
Rationale: Postpartum pelvic changes require diaphragm refitting to ensure effective contraception, as size may differ after childbirth.