Nokea
A toddler has been treated for sickle cell crisis. The crisis subsides, and the child improves. Which statement is essential for the nurse to include in the discharge teaching?
- A. Your child will bruise easily. Do not let your child bump into things.
- B. Notify the physician immediately if your child develops a fever.
- C. Your child will need special help with feeding.
- D. Observe your child frequently for difficulty breathing.
Correct Answer: B
Rationale: Fevers can cause dehydration and trigger sickling, leading to a crisis, making it essential to notify the physician immediately.
You may also like to solve these questions
The nurse is caring for the client experiencing superior vena cava syndrome secondary to lung cancer. Which problem should be the nurse’s priority?
- A. Ineffective breathing pattern
- B. Ineffective tissue perfusion
- C. Risk for infection
- D. Impaired skin integrity
Correct Answer: A
Rationale: A. Ineffective breathing pattern occurs with superior vena cava syndrome because the superior vena cava is located next to the main stem bronchus and causes compression of the intrathoracic structures. B. Ineffective tissue perfusion may occur with superior vena cava syndrome, but ineffective breathing pattern is priority. C. Risk for infection occurs with chemotherapy treatment and not from superior vena cava syndrome. D. Impaired skin integrity occurs with malignant skin conditions and usually not from lung cancer.
When reviewing the morning serum laboratory results of the client with multiple myeloma, the nurse sees that the total calcium level is 13.2 mEq/L. Which interventions, if prescribed by the HCP, should the nurse plan to implement?
- A. Encourage fluid intake.
- B. Maintain strict bedrest.
- C. Administer furosemide IV.
- D. Give allopurinol by mouth.
- E. Offer foods high in calcium.
Correct Answer: C
Rationale: A, C: A. Adequate hydration dilutes calcium and prevents precipitates from causing renal tubular obstruction. B. The client with multiple myeloma is encouraged to ambulate because weight-bearing activities can help the bone resorb some calcium as well as prevent thrombosis that can accompany immobility. C. Furosemide (Lasix) given IV can promote the excretion of calcium when hypercalcemia exists due to multiple myeloma. D. Allopurinol (Zyloprim) may be administered to reduce the hyperuricemia that can accompany multiple myeloma, not the hypercalcemia. E. The serum calcium level is elevated (normal is 9–10.5 mg/dL). Foods high in calcium would not be offered. However, limiting the intake of foods high in calcium will not make any difference to the elevated calcium level that is caused by cancer.
The client is hospitalized with a diagnosis of sickle cell crisis. Which findings should prompt the nurse to consider that the client is ready for discharge?
- A. Leukocyte count is at 7500/mm3
- B. Describes the importance of keeping warm
- C. Pain controlled at 2 on a 0 to 10 scale with analgesics
- D. Has not had chest pain or dyspnea for past 24 hours
- E. Blood transfusions effective in diminishing cell Sickling
- F. Hydroxyurea effective in suppressing leukocyte formation
Correct Answer: A, B, C, D
Rationale: leukocyte count of 7500/mm3 is within normal range (5000 to 10,000/mm3 indicates the absence of an infection). B. Keeping warm and avoiding chills will help to prevent infection. Cold causes vasoconstriction, slowing blood flow and aggravating the Sickling process. C. Acute pain is due to tissue hypoxia from the agglutination of sickled cells within blood vessels. D. The absence of symptoms of complication such as acute chest syndrome and pulmonary hypertension indicates readiness for discharge. E. RBC transfusions may help to prevent complications, but transfusions do not alter the person’s body from producing the deformed erythrocytes. F. Hydroxyurea (Hydrea) can decrease the permanent formation of sickled cells. A side effect (not therapeutic effect) of hydroxyurea is suppression of leukocyte formation.
The client had basal cell carcinoma (BCC) lesions excised the day before at an outpatient clinic. The client telephones the nurse expressing concerns that the wounds are draining watery, pale pink fluid and that the small dressing is leaking. Which action should the nurse recommend?
- A. Apply ice to the area
- B. Contact the surgeon
- C. Take pain medication
- D. Change the dressings
Correct Answer: D
Rationale: A. Applying ice to the area is not necessary because the client did not mention swelling. B. Since the wounds do not drain purulent material, contacting the physician is not necessary. C. Because the client is not experiencing pain, pain medication is not needed. D. The nurse should recommend changing the dressing because a small amount of serosanguineous drainage is a normal response to surgical removal of a lesion.
The client diagnosed with leukemia is being admitted for an induction course of chemotherapy. Which laboratory values indicate a diagnosis of leukemia?
- A. A left shift in the white blood cell (WBC) count differential.
- B. A large number of WBCs that decreases after the administration of antibiotics.
- C. An abnormally low hemoglobin (Hb) and hematocrit (Hct) level.
- D. Red blood cells (RBCs) that are larger than normal.
Correct Answer: C
Rationale: Leukemia causes bone marrow suppression, leading to low Hb/Hct (C). Left shift (A) indicates infection, antibiotic response (B) suggests infection, and large RBCs (D) indicate megaloblastic anemia.