Nokea
A child with a diagnosis of sickle cell disease is admitted to the hospital for treatment of vaso-occlusive pain crisis. The nurse should plan for which interventions in the care of the client? Select all that apply.
- A. Increase fluid intake.
- B. Administer oxygen.
- C. Administer meperidine.
- D. Perform frequent pain assessment.
- E. Administer intravenous (IV) fluids.
Correct Answer: A,B,D,E
Rationale: Management of the severe pain that occurs with vaso-occlusive crisis includes frequent pain assessment and the use of strong opioid analgesics, such as morphine sulfate and hydromorphone. Fluids are necessary to promote hydration, so options related to the delivery of fluids are appropriate. Oxygen is administered to increase tissue perfusion. Meperidine is contraindicated because of its side effects and increased risk of seizures after as few as 2 doses.
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A client with a history of gout is prescribed febuxostat (Uloric). The nurse should monitor the client for which of the following adverse effects?
- A. Hepatotoxicity.
- B. Hypoglycemia.
- C. Hypertension.
- D. Weight gain.
Correct Answer: A
Rationale: Febuxostat can cause hepatotoxicity, requiring liver function monitoring.
Which member of the multidisciplinary team would you most likely collaborate with when your pediatric client has had a traumatic amputation one or more months ago?
- A. A Pedorthist
- B. A pediatric nurse practitioner
- C. A trauma certified clinical nurse specialist
- D. A prosthetist
Correct Answer: D
Rationale: A prosthetist specializes in designing and fitting prosthetic limbs, making them the most appropriate team member to collaborate with for a pediatric client with a traumatic amputation.
The nurse is teaching a client with a new diagnosis of type 2 diabetes mellitus about dietary modifications. Which of the following foods should the client limit?
- A. Whole grains.
- B. Sugary beverages.
- C. Lean proteins.
- D. Non-starchy vegetables.
Correct Answer: B
Rationale: Sugary beverages should be limited in type 2 diabetes to prevent blood glucose spikes.
Your client has an allergy to both penicillin and latex. Which of these pathophysiological facts should you apply when you are providing to this client?
- A. The sensitizing dose of penicillin can lead to anaphylaxis.
- B. The second dose of penicillin can lead to distributive shock.
- C. You should be aware of the fact that about 10% of the population has an allergy to both penicillin and latex.
- D. You should be aware of the fact that about 20% of the population has an allergy to both penicillin and latex.
Correct Answer: A
Rationale: A sensitizing dose of penicillin can lead to anaphylaxis , a life-threatening allergic reaction, which is critical to consider when caring for a client with a penicillin allergy. The prevalence of dual allergies (C, D) is not accurate, and distributive shock is not specific to a second dose.
A client tells the nurse that she has had sexual contact with someone whom she suspects has genital herpes. Which of the following instructions should the nurse give the client in response to this information?
- A. Anticipate lesions within 25 to 30 days.
- B. Continue sexual activity unless lesions are present.
- C. Report any difficulty urinating.
- D. Drink extra fluids to prevent lesions from forming.
Correct Answer: C
Rationale: Difficulty urinating can indicate herpes-related urinary retention, a serious complication requiring medical attention.