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A client is admitted to the hospital in sickle cell crisis. For which clinical indicator should the nurse monitor the client?
- A. Pain
- B. Diarrhea
- C. Bradycardia
- D. Blurred vision
Correct Answer: A
Rationale: Sickle cell crisis usually causes severe pain in the bones and joints along with joint swelling. The pain develops as a result of microvascular occlusion from abnormal sickled hemoglobin that occurs with hypoxia. Therapy includes pain management with opioid analgesics, supplemental oxygen, and intravenous fluids. The remaining options are not associated with sickle cell crisis.
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The nurse is preparing a client for a thoracentesis. How should the nurse position the client for the procedure?
- A. Sitting with the arms over the head.
- B. Sims' position.
- C. Prone position without a pillow.
- D. Sitting forward with the arms supported on the bedside table.
Correct Answer: D
Rationale: Sitting forward with arms supported allows optimal access to the pleural space and ensures client comfort during thoracentesis.
A client with a history of heart failure is admitted with fatigue. The nurse should monitor the client for which of the following laboratory abnormalities?
- A. Elevated B-type natriuretic peptide (BNP).
- B. Decreased creatinine.
- C. Increased albumin.
- D. Decreased sodium.
Correct Answer: A, D
Rationale: Elevated BNP indicates heart failure severity, and hyponatremia is common due to fluid overload.
The nurse is teaching a client with a new diagnosis of atrial fibrillation about dabigatran (Pradaxa). Which of the following instructions is most important?
- A. Take the medication with food to reduce stomach upset.
- B. Report any signs of bleeding immediately.
- C. Avoid taking the medication with aspirin.
- D. Store the medication in the refrigerator.
Correct Answer: B
Rationale: Dabigatran, an anticoagulant, increases bleeding risk, so reporting signs of bleeding is critical for safety.
A client diagnosed with multiple sclerosis is prescribed baclofen. Which assessment finding would indicate to the nurse that the client is experiencing a therapeutic response from the medication?
- A. Decreased nausea
- B. Decreased muscle spasms
- C. Increased muscle tone and strength
- D. Increased range of motion of all extremities
Correct Answer: B
Rationale: Baclofen is a skeletal muscle relaxant and acts at the spinal cord level to decrease the frequency and amplitude of muscle spasms in clients with spinal cord injuries or diseases, or multiple sclerosis. None of the other options are related to the effects of this medication.
Identify this cardiac rhythm strip. Fill in the blank. A. Idioventricular Rhythm B. Bundle Branch Block C. Sinus bradycardia D. Atrial Flutter
- B. Idioventricular Rhythm
- C. Bundle Branch Block
- D. Sinus bradycardia
- E. Atrial Flutter
Correct Answer: C
Rationale: Sinus bradycardia is characterized by a regular rhythm with a rate below 60 beats per minute, assuming the strip shows this pattern.