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A nurse is discharging a child who has sickle cell anemia after an acute crisis episode. Which of the following instructions should the nurse include in the teaching?
- A. Offer fluids to your child multiple times every day
- B. Offer fluids only during fever episodes.
- C. Give fluids only if the child asks for them.
- D. Limit fluid intake during a crisis to reduce swelling.
Correct Answer: A
Rationale: The correct answer is A: Offer fluids to your child multiple times every day. This is important in sickle cell anemia to prevent dehydration and promote good blood flow, reducing the risk of sickling and subsequent crisis episodes. Adequate hydration helps maintain the flexibility of red blood cells and prevents them from clumping together. Options B, C, and D are incorrect because limiting fluid intake can lead to dehydration and worsen the symptoms of sickle cell anemia during and after a crisis episode. It is essential to encourage regular fluid intake to keep the child well-hydrated and prevent complications.
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A nurse is teaching a newly licensed nurse about gynecological examination. Which of the following information should the nurse include in the teaching?
- A. The urethral orifice is assessed by separating the labia minora.
- B. The cervix should be palpated for size.
- C. The vagina should be inspected without a speculum.
- D. The clitoris should be massaged during examination.
Correct Answer: A
Rationale: Correct Answer: A
Rationale: The urethral orifice is located between the clitoris and vaginal opening, so separating the labia minora is necessary to assess it. This step ensures proper assessment of the urinary system and helps detect any abnormalities.
Summary of Incorrect Choices:
B: Palpating the cervix for size is not a standard part of a gynecological examination; it may cause discomfort and is unnecessary unless indicated for specific medical reasons.
C: Inspecting the vagina without a speculum is not recommended as it may not provide a clear view of the vaginal walls and cervix, potentially missing important findings.
D: Massaging the clitoris is not a part of a gynecological examination and is inappropriate; it may be uncomfortable for the patient and is not relevant to the assessment.
A nurse is completing discharge teaching with a client following arthroscopic knee surgery. Which of the following instructions should the nurse include in the teaching?
- A. Keep the knee elevated above the heart at all times.
- B. Avoid physical therapy for 2 weeks.
- C. Apply ice to the affected area.
- D. Limit fluid intake to reduce swelling.
Correct Answer: C
Rationale: The correct answer is C: Apply ice to the affected area. Ice application helps reduce swelling and pain post-surgery. Keeping the knee elevated above the heart (A) is important, but not at all times as it can lead to other issues like blood pooling. Avoiding physical therapy for 2 weeks (B) is incorrect as early mobilization is crucial for recovery. Limiting fluid intake (D) is not recommended as hydration is essential for healing.
A nurse is teaching a client about the causes of osteoporosis. The nurse should include which of the following types of medication therapy as a risk factor for osteoporosis?
- A. Aspirin therapy
- B. Calcium supplements
- C. Estrogen therapy
- D. Thyroid hormones
Correct Answer: D
Rationale: The correct answer is D: Thyroid hormones. Excessive use of thyroid hormones can lead to osteoporosis by increasing bone turnover and reducing bone mineral density. Thyroid hormones can interfere with the normal process of bone formation and resorption, leading to weakened bones. Aspirin therapy (A) is not a risk factor for osteoporosis. Calcium supplements (B) are actually recommended to prevent osteoporosis. Estrogen therapy (C) is also not a risk factor; in fact, estrogen helps to maintain bone density.
A nurse is reviewing the laboratory findings for a client who developed fat embolism syndrome (FES) following a fracture. Which of the following laboratory findings should the nurse expect?
- A. Increased serum calcium level
- B. Decreased serum calcium level
- C. Increased white blood cell count
- D. Decreased platelet count
Correct Answer: B
Rationale: The correct answer is B: Decreased serum calcium level. In fat embolism syndrome (FES), fat globules enter the bloodstream, leading to blockages in small blood vessels. This can cause a decrease in serum calcium due to the formation of fat emboli in the pulmonary circulation, leading to hypoxia and subsequent release of inflammatory mediators that can affect calcium levels. The other choices are incorrect because in FES, there is no direct effect on serum calcium levels. Increased serum calcium levels (choice A) are not expected in FES. While increased white blood cell count (choice C) and decreased platelet count (choice D) can occur in response to inflammation or infection associated with FES, they are not specific laboratory findings for FES.
A nurse is caring for a client who develops a ventricular fibrillation rhythm. The client is unresponsive, pulseless, and apneic. Which of the following actions is the nurse's priority?
- A. Defibrillation
- B. Administer oxygen
- C. Call for help
- D. Start chest compressions
Correct Answer: A
Rationale: The correct answer is A: Defibrillation. Ventricular fibrillation is a life-threatening arrhythmia that requires immediate defibrillation to restore the heart's normal rhythm. Defibrillation is the priority as it is the most effective intervention to treat ventricular fibrillation and increase the chance of survival. Administering oxygen (B) is important but not the priority over defibrillation. Calling for help (C) should be done after initiating defibrillation. Starting chest compressions (D) should only be done if defibrillation is not immediately available or unsuccessful.