Nokea
The nurse is caring for the female client recovering from a sickle cell crisis. The client tells the nurse her family is planning a trip this summer to Yellowstone National Park. Which response would be best for the nurse?
- A. That sounds like a wonderful trip to take this summer.'
- B. Have you talked to your doctor about taking the trip?'
- C. You really should not take a trip to areas with high altitudes.'
- D. Why do you want to go to Yellowstone National Park?'
Correct Answer: C
Rationale: High altitudes (e.g., Yellowstone) reduce oxygen, risking SCA crisis (C). Generic praise (A), deferring to HCP (B), or questioning motive (D) are less direct.
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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 is preparing the client for a bone marrow biopsy of the iliac crest. Place the nurse’s actions in order of priority.
- A. Premedicate with lorazepam
- B. Obtain a signed informed consent
- C. Position prone and provide emotional support
- D. Verify that the HCP has explained the procedure
- E. Check for signs of bleeding every 2 hours for 24 hours
- F. Teach what may be expected during the procedure
Correct Answer: D, F, B, A, C, E:
Rationale: Verify that the HCP has explained the procedure. The HCP should include the purpose, intended outcomes, and potential complications. F. Teach what may be expected during the procedure, including that pressure or discomfort may be experienced. B. Obtain a signed informed consent. This is obtained only after the HCP has met with the client and teaching is completed. A. Premedicate with lorazepam (Ativan). Midazolam (Versed) is another option for sedation. A local anesthetic is used at the site, and some clients may not need sedation. C. Position prone and provide emotional support. The client should be prone because the iliac crest is the site being used for this biopsy, but the position will vary with the site. Holding the client’s hand and using guided imagery help support the client. E. Check for signs of bleeding every 2 hours for 24 hours. A pressure dressing is applied by the HCP after the procedure. Ice can be applied to reduce bruising and for comfort.
The client is diagnosed with non-Hodgkin’s lymphoma. Which nursing concept should the nurse identify as priority?
- A. Immunity.
- B. Grieving.
- C. Perfusion.
- D. Clotting.
Correct Answer: A
Rationale: NHL impairs immunity (A) via lymph node dysfunction, increasing infection risk, a priority. Grieving (B), perfusion (C), and clotting (D) are secondary.
The charge nurse in the intensive care unit is making client assignments. Which client should the charge nurse assign to the graduate nurse who has just finished the three (3)-month orientation?
- A. The client with an abdominal peritoneal resection who has a colostomy.
- B. The client diagnosed with pneumonia who has acute respiratory distress syndrome.
- C. The client with a head injury developing disseminated intravascular coagulation.
- D. The client admitted with a gunshot wound who has an H&H of 7 and 22.
Correct Answer: A
Rationale: Colostomy care (A) is stable and suitable for a new graduate. ARDS (B), DIC (C), and severe anemia (D) are critical, requiring experienced care.
Which sign/symptom should the nurse expect to assess in the client diagnosed with hemophilia A?
- A. Epistaxis.
- B. Petechiae.
- C. Subcutaneous emphysema.
- D. Intermittent claudication.
Correct Answer: A
Rationale: Hemophilia A causes bleeding; epistaxis (A) is common. Petechiae (B) indicate thrombocytopenia, emphysema (C) is unrelated, and claudication (D) is vascular.