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A nurse is caring for a client who has sickle cell anemia. The client asks, 'Why do I feel so tired and fatigued all of the time?' Which of the following information should the nurse provide?
- A. You have had a gastrointestinal bleed.
- B. You have a low ferritin level.
- C. You have an autoimmune disease.
- D. You have fewer red blood cells.
Correct Answer: D
Rationale: Sickle cell anemia causes fewer healthy red blood cells due to fragile sickled cells, leading to anemia and reduced oxygen delivery, causing fatigue.
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A nurse is assessing a client who has had staples removed from an abdominal wound postoperatively. The nurse notes separation of the wound edges with copious light-brown serous drainage. Which of the following actions should the nurse perform first?
- A. Check the client's vital signs.
- B. Cover the wound with a moist, sterile gauze dressing.
- C. Assess the client's pain level.
- D. Obtain a culture and sensitivity of the wound drainage
Correct Answer: B
Rationale: Covering the wound with a moist, sterile dressing is the priority to protect it from infection and manage drainage, preventing further contamination and supporting healing.
A nurse is reviewing discharge instructions with a client following a right cataract extraction. Which of the following instructions should the nurse include?
- A. Sleep on the abdomen to facilitate wound healing.
- B. Bend at the waist to pick objects up from the floor.
- C. Notify the surgeon if white drainage develops on the eyelids.
- D. Avoid lifting anything heavier than 4.5 kg (10 lb) for 1 week.
Correct Answer: D
Rationale: Lifting heavy objects can increase intraocular pressure, disrupting healing post-cataract surgery. Avoiding heavy lifting is critical. Other options risk complications or are unnecessary.
A nurse is teaching a group of clients about lifestyle modifications that could decrease risk factors for developing hearing loss. Which of the following risk factors should the nurse include in the teaching?
- A. Consume foods high in potassium
- B. Avoid smoking tobacco products
- C. increase oral intake of water
- D. Limit alcohol to two drinks daily
Correct Answer: B
Rationale: Smoking impairs blood flow to the cochlea and auditory nerve, increasing hearing loss risk. Potassium, hydration, and moderate alcohol are not directly linked to hearing loss prevention.
A nurse is planning nutritional teaching for a client who is experiencing fatigue due to iron deficiency anemia. Which of the following foods should the nurse recommend to the client?
- A. 1 cup canned black beans
- B. 8 a whole milk
- C. 1.5 oz raisins
- D. 8 or black tea
Correct Answer: A
Rationale: Black beans are high in iron, making them an excellent dietary choice for iron deficiency anemia. Milk can inhibit iron absorption due to calcium, raisins have less iron than beans, and tea contains tannins that reduce iron absorption.
Nurse's Notes:
Client admitted to the unit for a lower GI bleed. Continues to have frequent bloody stools and is scheduled for a lower endoscopy in 4 hr. The client is receiving their fourth unit of packed red blood cells (packed RBCs). Unit of fourth packed RBCs started at a rate of 250 cc/hr. Thirty minutes after the transfusion started, the client started reporting dyspnea and restlessness. Crackles auscultated in bilateral lower lobes. oxygen saturation 92% on 2L nasal cannula, and jugular vein distention noted.
Vital signs:
Temperature: 37.0°C (98.6°F)
Heart Rate (HR): 110 beats per minute
Blood Pressure (BP): 150/90 mmHg
Respiratory Rate (RR): 24 breaths per minute
Oxygen Saturation (SpO2): 92% on 2L nasal cannula
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
- A. Administer diphenhydramine, Administer an antibiotic, Administer furosemide, Stop transfusion
- B. Transfusion reaction, Transfusion associated circulatory overload, Acute extravasation
- C. Hives, Weight, Low back pain, Respiratory rate
Correct Answer: B,C,D
Rationale: The client is experiencing transfusion-associated circulatory overload (TACO), indicated by dyspnea, crackles, jugular vein distention, and hypertension. Stopping the transfusion prevents further fluid overload, and furosemide removes excess fluid. Monitoring weight and respiratory rate assesses fluid status and respiratory distress.