Nokea
A client is admitted with sickle cell crises and sequestration. Upon assessing the client, the nurse would expect to find:
- A. Decreased blood pressure
- B. Moist mucus membranes
- C. Decreased respirations
- D. Increased blood pressure
Correct Answer: A
Rationale: Sickle cell crisis with sequestration can lead to hypovolemia due to blood pooling in organs, resulting in decreased blood pressure.
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The nurse is caring for a client post-thyroidectomy. Which assessment finding requires immediate intervention?
- A. Mild incisional pain
- B. Tingling in the fingers
- C. Slight hoarseness
- D. Temperature of 99.5°F
Correct Answer: B
Rationale: Tingling in the fingers suggests hypocalcemia due to parathyroid gland damage, risking tetany or seizures, requiring immediate intervention. Pain (A), hoarseness (C), and mild fever (D) are expected post-op.
A client with angina is experiencing migraine headaches. The physician has prescribed Sumatriptan succinate (Imitrex). Which nursing action is most appropriate?
- A. Call the physician to question the prescription order.
- B. Try to obtain samples for the client to take home.
- C. Perform discharge teaching regarding this drug.
- D. Consult social services for financial assistance with obtaining the drug.
Correct Answer: A
Rationale: Sumatriptan, a triptan, is contraindicated in angina due to vasoconstrictive effects, risking coronary ischemia. Questioning the order (A) is priority. Samples (B), teaching (C), and financial aid (D) are inappropriate without resolving the contraindication.
A client has consented to have a central venous catheter placed. The best position in which to place the client is the Trendelenburg position. The reason is that the Trendelenburg position:
- A. Allows the physician to visualize the subclavian vein
- B. Reduces the possibility of air embolism
- C. Reduces the possibility of hematoma formation
- D. Makes the procedure more comfortable for the client
Correct Answer: B
Rationale: The Trendelenburg position reduces air embolism risk by increasing central venous pressure and distending veins for easier catheter insertion.
A client with a deep decubitus ulcer is receiving therapy in the hyperbaric oxygen chamber. Before therapy, the nurse should:
- A. Apply a lanolin-based lotion to the skin.
- B. Wash the skin with water and pat dry.
- C. Cover the area with a petroleum gauze.
- D. Apply an occlusive dressing to the site.
Correct Answer: B
Rationale: Clean, dry skin is required before hyperbaric oxygen therapy to prevent infection and ensure effective oxygen delivery. Lotions, petroleum, or dressings can interfere or pose fire risks.
The client tells the nurse, 'I have pain in my left shoulder.' This is considered:
- A. Evaluation process
- B. Objective information
- C. Subjective information
- D. Complaining
Correct Answer: C
Rationale: Subjective information is provided by a person.