Nokea
A nurse is preparing a room for the admission of a client with sickle cell anemia who is in vasoocclusive crisis. Which type of equipment should the nurse place in the client's room?
- A. Wheelchair with adjustable leg rests
- B. A radio and age-appropriate reading materials
- C. Extra blankets and pillows
- D. Blood transfusion equipment
Correct Answer: D
Rationale: The correct answer is D: Blood transfusion equipment. In a vasoocclusive crisis, the client with sickle cell anemia may require blood transfusions to improve oxygen delivery to tissues. Having blood transfusion equipment readily available in the client's room ensures prompt initiation of treatment. Wheelchair (A) and comfort items like extra blankets and pillows (C) are important but not essential during a vasoocclusive crisis. A radio and reading materials (B) are not directly related to the client's immediate medical needs.
You may also like to solve these questions
A nurse is holding an infant during a lumbar puncture for a suspicion of meningitis. The infant is in a sitting position with the buttocks at the edge of the table and the neck flexed, and the nurse is immobilizing the infant's arms and legs. Which assessment takes priority during the procedure?
- A. Circulation checks of the lower extremities
- B. Heart rate and crying pattern
- C. Chest expansion and diaphragm excursion
- D. Clarity of spinal fluid and level of consciousness
Correct Answer: C
Rationale: Chest expansion is critical due to the infant's position, which may limit breathing.
A nurse is monitoring a child whose parents are suspected of child neglect. Which of the following is an expected finding of neglect?
- A. Lack of required immunizations
- B. Parental lack of education
- C. Lower socioeconomic group
- D. Faded clothing with large shoes
Correct Answer: A
Rationale: The correct answer is A: Lack of required immunizations. Neglect refers to the failure to provide for a child's basic needs, including healthcare. Lack of immunizations puts the child at risk for preventable diseases, indicating neglect. Parental lack of education (B) or being in a lower socioeconomic group (C) do not directly indicate neglect. Faded clothing with large shoes (D) may suggest financial difficulties but does not necessarily indicate neglect.
A nurse is caring for a child with muscular dystrophy. Which of the following priority actions should the nurse include in the care of this child?
- A. Limit physical activity and plan frequent rest periods to avoid overexertion and exhaustion of muscle groups.
- B. Recommend genetic counseling for parents,male siblings and paternal uncles and their male offspring.
- C. Advise against flu and pneumococcal vaccines due to a compromised respiratory system.
- D. Have the child use an incentive spirometer and perform breathing exercises routinely.
Correct Answer: D
Rationale: The correct answer is D: Have the child use an incentive spirometer and perform breathing exercises routinely. This is the priority action because children with muscular dystrophy are at risk for respiratory complications due to weakened respiratory muscles. Using an incentive spirometer and performing breathing exercises help maintain lung function and prevent respiratory infections.
A: Limiting physical activity and planning rest periods is important, but respiratory care takes precedence in muscular dystrophy.
B: Genetic counseling is important for family planning but does not directly impact the child's care.
C: Advising against vaccines can increase the risk of infections in a child with compromised respiratory function.
E, F, G: No information provided.
A nurse is reinforcing teaching given to the parent of a 1-year-old child who has had a high temperature, vomiting, and diarrhea for 48 hr. The child has sunken eyes and cracked lips. Which of the following should the nurse tell the parent?
- A. Give the infant applesauce and rice cereal because these have been found to have high nutritional value.
- B. Encourage the child to take sips of chicken or beef broth because they will replace the fluid losses your child is experiencing.
- C. Give the infant oral rehydration solutions that are available commercially. They replace some of the electrolytes lost through vomiting.
- D. Give the child nothing by mouth for 4 hr. Once the vomiting has decreased you can introduce sips of clear water.
Correct Answer: C
Rationale: Oral rehydration solutions effectively replace fluids and electrolytes lost due to vomiting and diarrhea.
A nurse is caring for a prenatal client who has parvovirus B19 (fifth disease). Which of the following actions should the nurse take?
- A. Administer antiviral medication
- B. Schedule an ultrasound examination
- C. Administer Haemophilus influenza type b vaccine
- D. Schedule an indirect Coombs’ test
Correct Answer: B
Rationale: The correct answer is B: Schedule an ultrasound examination. Parvovirus B19 in pregnancy can lead to complications such as fetal hydrops. An ultrasound can monitor fetal well-being and detect any abnormalities. Administering antiviral medication (A) is not typically recommended for parvovirus B19. Administering the Haemophilus influenza type b vaccine (C) is unrelated to this condition. Performing an indirect Coombs' test (D) is used to detect maternal antibodies in Rh incompatibility, not related to parvovirus B19.