Nokea
The mother of a one-year-old with sickle cell anemia wants to know why the condition didn't show up in the nursery. The nurse's response is based on the knowledge that:
- A. There is no test to measure abnormal hemoglobin in newborns.
- B. Infants do not have insensible fluid loss before a year of age.
- C. Infants rarely have infections that would cause them to have a sickling crises.
- D. The presence of fetal hemoglobin protects the infant.
Correct Answer: D
Rationale: Fetal hemoglobin (HbF), predominant in newborns, inhibits sickling in sickle cell anemia, delaying symptoms until HbF decreases around 6 months. Newborn screening exists, and infections can trigger crises later.
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The nurse explains perineal hygiene self-care postpartum to the client. She should be instructed to:
- A. Wear gloves for the procedure
- B. Place and adjust the pad from back to front
- C. Cleanse and wipe the perineum from front to back
- D. Protect the outer surface of the pad from contamination
Correct Answer: C
Rationale: (Tom) Perineal hygiene is a clean procedure and does not require the client to wear gloves. A care provider should wear gloves to adhere to universal precautions. The pad should be applied from front to back to prevent contamination of the birth canal or urinary tract from rectal bacteria. Wiping from front to back and discarding the wipe prevents contamination of the urinary tract and birth canal from rectal bacteria. The inner surface of the pad should not be touched to maintain asepsis.
A client is hyperactive and not sleeping. She will not remain at the table during mealtime. She is getting very limited calories and is using a lot of energy in her hyperactive state. The most therapeutic nursing action is to:
- A. Insist that she remain at the table and eat a balanced diet.
- B. Order a high-calorie diet with supplements.
- C. Provide nutritious finger foods several times a day.
- D. Offer to go to the dining room with her and allow her to open the food and inspect what she eats.
Correct Answer: C
Rationale: Providing finger foods increases the likelihood of eating for hyperactive persons. They may be eating 'on the run,' accommodating their high energy state.
A client is admitted with sickle cell crises and sequestration. Upon assessing the client, the nurse would expect to find:
- A. Decreased blood pressure
- B. Moist mucus membranes
- C. Decreased respirations
- D. Increased blood pressure
Correct Answer: A
Rationale: Sickle cell crisis with sequestration can lead to hypovolemia due to blood pooling in organs, resulting in decreased blood pressure.
A client is admitted to the hospital with diabetic ketoacidosis. The emergency room nurse should anticipate the administration of:
- A. Humulin N
- B. Humulin R
- C. Humulin U
- D. Humulin L
Correct Answer: B
Rationale: Regular insulin is rapid acting and indicated in an emergency situation.
The doctor has prescribed aspirin 325 mg daily for a client with transient ischemic attacks. The nurse explains that aspirin was prescribed to:
- A. Prevent headaches
- B. Boost coagulation
- C. Prevent cerebral anoxia
- D. Decrease platelet aggregation
Correct Answer: D
Rationale: Aspirin reduces platelet aggregation, preventing clot formation in transient ischemic attacks, reducing stroke risk. It does not prevent headaches, boost coagulation, or directly prevent anoxia.