Nokea
A woman is admitted to the labor and delivery unit in a sickle cell crisis. Which of the following nursing actions is the HIGHEST priority?
- A. Administer oxygen.
- B. Turn her to the right side.
- C. Provide adequate hydration.
- D. Start antibiotics.
Correct Answer: C
Rationale: adequate hydration is a priority for any client with sickle cell crisis
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A client is scheduled for knee replacement surgery, and the nurse is reviewing preoperative laboratory results. The nurse should notify the physician about which of the following abnormal laboratory results?
- A. Platelets 119,000.
- B. Glucose 83.
- C. Hemoglobin 13.7.
- D. Sodium 141.
Correct Answer: A
Rationale: A platelet count of 119,000 (A) is below the normal range (150,000-450,000), increasing bleeding risk during surgery, and should be reported. Glucose 83 (B), hemoglobin 13.7 (C), and sodium 141 (D) are within normal limits.
The home health nurse is visiting a client with Paget's disease. An important part of preventive care for the client with Paget's disease is:
- A. Keeping the environment free of clutter
- B. Advising the client to see the dentist regularly
- C. Encouraging the client to take the influenza vaccine
- D. Telling the client to take a daily multivitamin
Correct Answer: A
Rationale: Paget's disease increases fracture risk, so keeping the environment clutter-free reduces fall risks, a key preventive measure.
The physician has discussed the need for medication with the parents of an infant with congenital hypothyroidism. The nurse can reinforce the physician's teaching by telling the parents that:
- A. The medication will be needed only during times of rapid growth.
- B. The medication will be needed throughout the child's lifetime.
- C. The medication schedule can be arranged to allow for drug holidays.
- D. The medication is given one time daily every other day.
Correct Answer: B
Rationale: Congenital hypothyroidism requires lifelong thyroid hormone replacement therapy to maintain normal metabolism and development.
A primigravida with(choices truncated due to document error; assuming standard options for context) diabetes is admitted to the labor and delivery unit at 34 weeks gestation. Which doctor's order should the nurse question?
- A. Magnesium sulfate 4 gm (25%) IV
- B. Brethine 10 mcg IV
- C. Stadol 1 mg IV push every 4 hours as needed prn for pain
- D. Ancef 2 gm IVPB every 6 hours
Correct Answer: B
Rationale: Brethine (terbutaline) is a tocolytic that can exacerbate maternal diabetes by causing hyperglycemia, so this order should be questioned in a diabetic primigravida.
The nurse is caring for a client with a diagnosis of major depressive disorder. Which of the following client statements would indicate that the client is responding positively to the prescribed antidepressant therapy?
- A. I feel like my energy level is starting to improve.
- B. I still don’t enjoy doing things I used to love.
- C. I have trouble sleeping through the night.
- D. I feel worthless and don’t want to see anyone.
Correct Answer: A
Rationale: improved energy level is a positive sign of response to antidepressant therapy