Nokea
The nurse is caring for a child with sickle cell anemia who is experiencing a vaso-occlusive crisis. Which of the following interventions is the priority?
- A. Administer oxygen.
- B. Provide hydration.
- C. Apply warm compresses.
- D. Administer analgesics.
Correct Answer: B
Rationale: Hydration is the priority in vaso-occlusive crisis to reduce blood viscosity and promote circulation, preventing further sickling and complications.
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A client with a history of cirrhosis is admitted with hepatic encephalopathy. The nurse should include which of the following in the plan of care?
- A. Administer lactulose as prescribed.
- B. Encourage a high-protein diet.
- C. Restrict fluid intake.
- D. Administer sedatives for agitation.
Correct Answer: A
Rationale: Lactulose reduces ammonia levels in hepatic encephalopathy.
You are providing care to a permanently disabled Iraqi war veteran who is 28 years of age. When he returned home from the war at the age of years of age 2 years ago he was deemed permanently disabled by both the Veterans Administration (VA) and the Social Security Administration. He receives a substantial monthly service connected disability check from the Veterans Administration and he has no spouse or legal dependents. Which type of governmental health insurance is he now entitled to?
- A. Only the VA health care services because he is not 65 years of age
- B. Medicare because he has been deemed permanently disabled for 2 years
- C. Medicaid because he is permanently disabled and not able to work
- D. Choices B and C
Correct Answer: B
Rationale: Individuals deemed permanently disabled by the Social Security Administration for at least 24 months are eligible for Medicare, regardless of age . The veteran is also eligible for VA healthcare, but option A incorrectly states 'only' VA services. Medicaid eligibility depends on income and state criteria, which are not confirmed here.
The nurse is preparing to insert a urinary catheter. Which action ensures sterile technique?
- A. Cleanse the meatus with an alcohol swab
- B. Use clean gloves during insertion
- C. Apply sterile lubricant to the catheter tip
- D. Insert the catheter without a drape
Correct Answer: C
Rationale: Applying sterile lubricant to the catheter tip maintains sterile technique, reducing the risk of infection during urinary catheter insertion.
A client asks the nurse how long she has to take her medicine for hypothyroidism. The nurse's response is based on the knowledge that:
- A. Lifelong daily medicine is necessary.
- B. The medication is expensive, and the dose can be reduced in a few months.
- C. The medication can be gradually withdrawn in 1 to 2 years.
- D. The medication can be discontinued after the client's thyroid-stimulating hormone level is normal.
Correct Answer: A
Rationale: Hypothyroidism typically requires lifelong thyroid hormone replacement therapy, as the condition is usually permanent due to underlying thyroid dysfunction.
A multigravid client at 36 weeks' gestation who is visiting the clinic for a routine visit begins to sob and tells the nurse, 'My boyfriend has been beating me up once in a while since I became pregnant'”but I can't bring myself to leave him because I don't have a job and I don't know how I would take care of my other children.' Which of the following actions should be the priority by the nurse at this time?
- A. Contact a social worker for assistance and family counseling.
- B. Help the client make concrete plans for the safety of herself and her children.
- C. Tell the client and how anyone to hit her or her children.
- D. Provide the client with brochures on the statistics about violence against women.
Correct Answer: B
Rationale: Prioritizing safety planning protects the client and her children from further abuse.