Nokea
A client with sickle cell disease is admitted in active labor. Which nursing intervention would be most helpful in preventing a sickling crisis?
- A. Obtaining blood pressures every two hours
- B. Administering pain medication every three hours as ordered
- C. Monitoring arterial blood gas results
- D. Administering IV fluids at ordered rate of 200 mL/hr
Correct Answer: D
Rationale: IV fluids at 200 mL/hr prevent dehydration, a trigger for sickling crises, by maintaining hydration and blood flow. BP monitoring (A), pain medication (B), and ABGs (C) are supportive but less directly preventive.
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At 16 weeks' gestation, a pregnant client is admitted to the maternity unit to have a McDonald procedure (cerclage) done. She tells the RN who is admitting her to the unit that her physician had explained what this procedure was, but that she did not understand. The RN explains to the client that the purpose for this procedure is to:
- A. Reinforce an incompetent cervix
- B. Repair the amniotic sac
- C. Evaluate cephalopelvic disproportion
- D. Dilate the cervix
Correct Answer: A
Rationale: The treatment most commonly uses the Shirodkar-Barter procedure (McDonald procedure) or cerclage to enforce the weakened cervix by encircling it with a suture at the level of the internal os. There is no known procedure that is used to repair the amniotic sac. Cephalopelvic disproportion is evaluated later in pregnancy. It is not related to this procedure. No procedure is done to dilate the cervix at 16 weeks' gestation unless the pregnancy is to be terminated.
A patient with thrombocytopenia has a platelet count of 80,000. It will be most important to teach the client about:
- A. Measures to reduce the risk of bleeding
- B. Increasing the fluid intake
- C. Activities to improve oxygenation
- D. Ways to conserve energy
Correct Answer: A
Rationale: Thrombocytopenia (low platelet count) increases bleeding risk. Teaching measures to reduce bleeding (e.g. avoiding trauma using soft toothbrushes) is critical. Fluid intake oxygenation and energy conservation are less directly related to the condition.
A client is taking Deltasone (prednisone) each morning to treat his systemic lupus erythematosus. Which statement best explains the reason for taking the prednisone in the morning?
- A. There is less chance of forgetting the medication if taken in the morning.
- B. There will be less fluid retention if taken in the morning.
- C. The medication is absorbed best with the breakfast meal.
- D. Morning administration mimics the body's natural secretion of corticosteroid.
Correct Answer: D
Rationale: Prednisone is taken in the morning to mimic the body’s natural cortisol peak, which occurs early in the day, minimizing adrenal suppression and side effects. Timing does not primarily affect forgetting, fluid retention, or absorption.
The nurse is assessing breath sounds in a bronchovesicular client. She should expect that:
- A. Inspiration is longer than expiration
- B. Breath sounds are high pitched
- C. Breath sounds are slightly muffled
- D. Inspiration and expiration are equal
Correct Answer: D
Rationale: Inspiration is normally longer in vesicular areas. High-pitched sounds are normal in bronchial area. Muffled sounds are considered abnormal. Inspiration and expiration are equal normally in this area, and sounds are medium pitched.
A client is admitted to the hospital with diabetic ketoacidosis. The emergency room nurse should anticipate the administration of:
- A. Humulin N
- B. Humulin R
- C. Humulin U
- D. Humulin L
Correct Answer: B
Rationale: Regular insulin is rapid acting and indicated in an emergency situation.