Nokea
The client diagnosed with sickle cell anemia comes to the emergency department complaining of joint pain throughout the body. The oral temperature is 102.4°F and the pulse oximeter reading is 91%. Which action should the emergency department nurse implement first?
- A. Request arterial blood gases STAT.
- B. Administer oxygen via nasal cannula.
- C. Start an IV with an 18-gauge angiocath.
- D. Prepare to administer analgesics as ordered.
Correct Answer: B
Rationale: SpO2 91% and fever suggest hypoxia in SCA crisis; oxygen via cannula (B) addresses this first. ABGs (A), IV (C), and analgesics (D) follow to confirm hypoxia, hydrate, and manage pain.
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The client diagnosed with sickle cell anemia asks the nurse, 'Should I join the Sickle Cell Foundation? I received some information from the Sickle Cell Foundation. What kind of group is it?' Which statement is the best response by the nurse?
- A. It is a foundation that deals primarily with research for a cure for SCA.'
- B. It provides information on the disease and on support groups in this area.'
- C. I recommend joining any organization that will help deal with your disease.'
- D. The foundation arranges for families that have children with sickle cell to meet.'
Correct Answer: B
Rationale: The Sickle Cell Foundation offers education and support groups (B). Research (A) is partial, generic advice (C) is vague, and family meetings (D) are not primary.
Which concepts could the nurse identify for a client diagnosed with lymphoma? Select all that apply.
- A. Coping.
- B. Hematologic regulation.
- C. Tissue perfusion.
- D. Clotting.
- E. Clinical judgment.
Correct Answer: A,B,C,D
Rationale: Lymphoma involves coping (A) with diagnosis, hematologic regulation (B) via lymph dysfunction, perfusion (C) due to node obstruction, and clotting (D) from thrombocytopenia. Clinical judgment (E) is a nursing process, not a patient concept.
The nurse writes a diagnosis of altered tissue perfusion for a client diagnosed with anemia. Which interventions should be included in the plan of care? Select all that apply.
- A. Monitor the client’s hemoglobin and hematocrit.
- B. Move the client to a room near the nurse’s desk.
- C. Limit the client’s dietary intake of green vegetables.
- D. Assess the client for numbness and tingling.
- E. Allow for rest periods during the day for the client.
Correct Answer: A,D,E
Rationale: Monitoring Hb/Hct (A), assessing numbness/tingling (D), and rest periods (E) address perfusion in anemia. Proximity to desk (B) is nonspecific, and limiting greens (C) is for anticoagulation, not anemia.
The nurse is admitting a client with a diagnosis of rule-out Hodgkin's lymphoma. Which assessment data support this diagnosis?
- A. Night sweats and fever without 'chills.'
- B. Edematous lymph nodes in the groin.
- C. Malaise and complaints of an upset stomach.
- D. Pain in the neck area after a fatty meal.
Correct Answer: A
Rationale: Night sweats and fever (A) are classic Hodgkin’s B symptoms. Edematous nodes (B) are not typical (firm, non-tender), malaise/stomach (C) is nonspecific, and neck pain (D) suggests gallbladder issues.
The client receiving a unit of PRBCs begins to chill and develops hives. Which action should be the nurse’s first response?
- A. Notify the laboratory and health-care provider.
- B. Administer the histamine-1 blocker, Benadryl, IV.
- C. Assess the client for further complications.
- D. Stop the transfusion and change the tubing at the hub.
Correct Answer: D
Rationale: Chills/hives suggest a transfusion reaction; stopping the transfusion at the hub (D) prevents further reaction. Assessment (C), Benadryl (B), and notification (A) follow.