Nokea
The nurse is caring for assigned clients. The nurse should first check the client with
- A. sickle cell disease who has new onset pain rated as 9 on a scale of 0-10
- B. pneumonia who has a temperature of 100.6°F (38.1°C) and is receiving IV antibiotics
- C. Graves’ disease who has a heart rate of 110/min and a blood pressure of 122/85 mm Hg
- D. diabetes mellitus who has an elevated serum glucose level and is requesting insulin lispro prior to a meal
Correct Answer: A
Rationale: Severe pain (9/10) in sickle cell disease indicates a possible vaso-occlusive crisis, a medical emergency requiring immediate assessment. Fever, tachycardia, and hyperglycemia are less urgent.
You may also like to solve these questions
A graduate student, who has been studying for final exams and using energy drinks to stay awake, comes to the clinic reporting a fluttering feeling in the chest. The student is connected to the cardiac monitor that displays the rhythm in the exhibit. The nurse recognizes this as which rhythm?
- A. Atrial fibrillation
- B. Sinus rhythm with premature atrial contractions
- C. Sinus rhythm with premature ventricular contractions
- D. Ventricular tachycardia
Correct Answer: B
Rationale: The fluttering feeling and irregular rhythm suggest premature atrial contractions, often triggered by stimulants like energy drinks. Atrial fibrillation shows chaotic waves, ventricular contractions have wide QRS complexes, and ventricular tachycardia is life-threatening, not matching the description.
The nurse is performing a sterile dressing change for a client when a second client begins yelling for pain medication. Which of the following actions should the nurse take?
- A. Ask unlicensed assistive personnel (UAP) to take the second client’s vital signs and report back immediately
- B. Direct UAP to ask the second client to rate the pain on a 0-10 scale and report back immediately
- C. Inform UAP to tell the second client that the nurse will be there soon and complete the sterile dressing change
- D. Interrupt the dressing change to medicate the second client
Correct Answer: C
Rationale: Completing the sterile dressing change maintains sterility and infection control, while informing the UAP to reassure the second client ensures their needs are addressed promptly without compromising the first client’s care.
Which symptom is considered an adverse reaction to Kantrex (kanamycin)?
- A. Diminished hearing
- B. Hypotension
- C. Hepatomegaly
- D. Petechiae
Correct Answer: A
Rationale: Kanamycin, an aminoglycoside, is ototoxic, and diminished hearing is a known adverse reaction requiring monitoring.
A client is admitted with diabetic ketoacidosis (DKA). Which laboratory finding requires immediate intervention by the nurse?
- A. Blood glucose of 450 mg/dL
- B. Potassium level of 4.0 mEq/L
- C. PaO2 of 92 mmHg
- D. HCT of 60
Correct Answer: C
Rationale: This high hematocrit is indicative of severe dehydration which requires priority attention in diabetic ketoacidosis. Without sufficient hydration, all systems of the body are at risk for hypoxia from a lack of or sluggish circulation.
The nurse is caring for an elderly client after hip replacement surgery. The client is distressed because he has not had a bowel movement in 3 days. Which action by the nurse would be most appropriate?
- A. Administer the prescribed as-needed milk of magnesia
- B. Ask dietary services to add more fruits and vegetables to the client’s tray
- C. Notify the registered nurse
- D. Perform a focused abdominal assessment
Correct Answer: D
Rationale: A focused abdominal assessment determines the cause of constipation (e.g., impaction, obstruction) before interventions like laxatives, dietary changes, or RN notification, ensuring safe and targeted care.