Nokea
The nurse identified clotting as a concept related to sickle cell disease. Which intervention should the nurse implement?
- A. Assess for cerebrovascular symptoms.
- B. Keep the head of the bed elevated.
- C. Order a 2,000-mg sodium diet.
- D. Apply antiembolism stockings.
Correct Answer: A
Rationale: SCD causes vaso-occlusion; assessing cerebrovascular symptoms (A) detects stroke risk. HOB elevation (B) is for ICP, sodium diet (C) is for hypertension, and stockings (D) are for DVT.
You may also like to solve these questions
The client diagnosed with leukemia has central nervous system involvement. Which instruction should the nurse teach?
- A. Sleep with the HOB elevated to prevent increased intracranial pressure.
- B. Take an analgesic medication for pain only when the pain becomes severe.
- C. Explain radiation therapy to the head may result in permanent hair loss.
- D. Discuss end-of-life decisions prior to cognitive deterioration.
Correct Answer: D
Rationale: CNS leukemia risks cognitive decline; discussing end-of-life decisions (D) is critical before deterioration. HOB elevation (A) is for ICP, not routine, analgesics (B) should be proactive, and hair loss (C) is secondary.
The nurse writes a diagnosis of 'potential for fluid volume deficit related to bleeding' for a client diagnosed with disseminated intravascular coagulation (DIC). Which would be an appropriate goal for this client?
- A. The client’s clot formations will resolve in two (2) days.
- B. The saturation of the client’s dressings will be documented.
- C. The client will use lemon-glycerin swabs for oral care.
- D. The client’s urine output will be greater than 30 mL per hour.
Correct Answer: D
Rationale: DIC risks bleeding/fluid loss; urine output >30 mL/hr (D) indicates adequate volume. Clot resolution (A) is unrealistic, dressing saturation (B) is an intervention, and swabs (C) are unrelated.
The client diagnosed with anemia begins to complain of dyspnea when ambulating in the hall. Which intervention should the nurse implement first?
- A. Apply oxygen via nasal cannula.
- B. Get a wheelchair for the client.
- C. Assess the client’s lung fields.
- D. Assist the client when ambulating in the hall.
Correct Answer: B
Rationale: Dyspnea in anemia suggests low oxygen-carrying capacity; a wheelchair (B) prevents exertion while further assessment occurs. Oxygen (A), lung assessment (C), and assistance (D) follow.
The nurse is teaching the client who is a strict vegetarian how to decrease the risk of developing megaloblastic anemia. Which information should the nurse provide?
- A. Undergo an annual Schilling test.
- B. Increase intake of foods high in iron.
- C. Supplement the diet with vitamin B12.
- D. Have a hemoglobin level drawn monthly.
Correct Answer: C
Rationale: A. The Schilling test is used to diagnose vitamin B12 deficiency; it is not necessary to have this completed annually. B. Consuming foods high in iron will prevent iron-deficiency, not megaloblastic, anemia. C. The client consuming a vegetarian diet can prevent megaloblastic anemia from a vitamin B12 deficiency with oral vitamin supplements or fortified soy milk. D. Monthly lab work is unnecessary and costly.
The client who has renal cancer that has metastasized rates pain at a 9 on a 0 to 10 pain scale. Which medication should the nurse plan to administer now and then schedule to be administered at the prescribed dosing interval?
- A. Meperidine
- B. Propoxyphene
- C. Pentazocine
- D. Oxycodone
Correct Answer: D
Rationale: A. Meperidine (Demerol) is not recommended because it causes CNS toxicity from metabolites. It should not be used for the treatment of chronic pain. B. Propoxyphene