Nokea
The nurse is caring for a client in a sickle cell crisis. Which is the pain regimen of choice to relieve the pain?
- A. Frequent aspirin (acetylsalicylic acid) and a nonnarcotic analgesic.
- B. Motrin (ibuprofen), a nonsteroidal anti-inflammatory drug (NSAID), prn.
- C. Demerol (meperidine), a narcotic analgesic, every four (4) hours.
- D. Morphine, a narcotic analgesic, every two (2) to three (3) hours prn.
Correct Answer: D
Rationale: Morphine PRN (D) is preferred for severe SCA crisis pain, titrated to relief. Aspirin (A) and ibuprofen (B) are insufficient and risk bleeding, and meperidine (C) risks seizures.
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In which order should the nurse address the assessment findings for the client who has undergone a total laryngectomy? Place the findings in the order of priority.
- A. Copious oral secretions and nasal mucus draining from the nose
- B. Restless and has a mucus plug in the tracheostomy
- C. NG tube used for intermittent feedings pulled halfway out
- D. Oozing serosanguineous drainage around the tracheostomy tube and dressing saturated
Correct Answer: B, A, D, C
Rationale: . Restless and has a mucus plug in the tracheostomy is priority requiring immediate attention due to the negative impact on air exchange. The client needs immediate suctioning. A. Copious oral secretions and nasal mucus draining from the nose should be next. After a total laryngectomy the mouth does not communicate with the trachea, so copious oral secretions and nasal drainage would not influence air exchange, but these create a source of discomfort for the client. D. Oozing serosanguineous drainage around the tracheostomy tube and saturated dressing should be addressed third. Changing the dressing now would allow the nurse to inspect the site and ensure tube patency. C. NG tube used for intermittent feedings pulled halfway out can be addressed last. There is no indication that a tube feeding is infusing. The HCP should be contacted to reinsert the NG tube to prevent disruption of the suture line in the esophagus.
The nurse explains “watchful waiting” (ongoing visits to a physician for observation of signs and symptoms without treatment) to the client with prostate cancer. Which client is a candidate for “watchful waiting”?
- A. 50-year-old with prostate cancer that has metastasized to the bone
- B. 75-year-old expected to live 5 years and has low-grade disease
- C. 45-year-old who has extension of the tumor outside of the prostate
- D. 59-year-old who is asymptomatic with an elevated prostate-specific antigen
Correct Answer: B
Rationale: A. The client with prostate cancer that has metastasized to the bone generally requires aggressive therapy. B. The client is a candidate for “watchful waiting” when older than age 70 with a life expectancy of less than 10 years and with low-grade disease. C. The client with extension of the tumor outside of the prostate generally requires aggressive therapy. D. The client who is asymptomatic with an elevated prostate-specific antigen generally requires aggressive therapy.
A child with leukemia bruises easily. This is most likely due to which of the following?
- A. Decreased fibrinogen levels
- B. Excessive clotting elsewhere in the body
- C. Decreased platelets
- D. Decreased erythrocytes
Correct Answer: C
Rationale: Leukemia causes bone marrow failure, leading to decreased platelets, which results in easy bruising.
The client is diagnosed with hereditary spherocytosis. Which treatment/procedure would the nurse prepare the client to receive?
- A. Bone marrow transplant.
- B. Splenectomy.
- C. Frequent blood transfusions.
- D. Liver biopsy.
Correct Answer: B
Rationale: Spherocytosis causes hemolytic anemia; splenectomy (B) reduces RBC destruction. BMT (A) is for leukemia, transfusions (C) are supportive, and liver biopsy (D) is unrelated.
The client diagnosed with von Willebrand’s disease calls a clinic after experiencing hemarthrosis. The client states that factor concentrate is infusing. Which intervention should the nurse recommend now?
- A. “Take two 325-mg aspirin tablets every 4 hours for pain.”
- B. “Apply a cold pack to the area for 30 minutes every 1 to 2 hours.”
- C. “Come to the clinic; you need an infusion of fresh frozen plasma.”
- D. “If wearing a splint, remove it to avoid compartment syndrome.”
Correct Answer: B
Rationale: A. Aspirin (Ecotrin) and NSAIDs are contraindicated because they interfere with platelet aggregation. B. Hemarthrosis is bleeding into the joint. The pressure of the ice pack and cold will reduce the bleeding and swelling. The ice pack should be covered with a cloth. C. The client and family are usually taught how to administer factor concentrates at home at the first sign of bleeding. D. The splint should be left on initially to control bleeding. The client should be instructed on how to assess for adequate tissue perfusion.