Nokea
The nurse is discharging an adolescent with sickle cell disease. Which statement should the nurse include in the teaching?
- A. Keep a water bottle with you at school so that you can stay hydrated
- B. Follow a high-calorie, high-protein diet
- C. Do not take the annual influenza vaccine
- D. Drink extra fluids if you have to travel on an airplane
- E. Daily aerobic exercise is recommended
Correct Answer: A, B, D
Rationale: Hydration, high-calorie/protein diet, and extra fluids during travel help prevent sickle cell crises. The influenza vaccine is recommended, and excessive aerobic exercise may trigger crises.
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The following scenario applies to the next 1 items
The nurse is caring for a client in active labor
Item 1 of 1
Nurses’ Note
23-year-old primipara at 39 gestational weeks was admitted for induction via oxytocin. Currently, she is 100% effaced and 10 cm dilated. An internal fetal spiral electrode and intrauterine pressure catheter were placed. Uterine contractions are now 2 to 2.5 minutes apart, 70 to 90 seconds in duration. The fetal heart tracing showed decreased fetal heart rate following uterine contraction. This pattern was present in more than 50% of the uterine contractions.
Medications
Oxytocin via continuous infusion
Complete the following sentence from the list of options. Based on the fetal heart rate tracing, the client is experiencing ___ that is caused by ___
- A. late decelerations
- B. early decelerations
- C. variable decelerations
- D. reduced blood flow to the placenta
- E. umbilical cord compression
- F. fetal head compression
Correct Answer: A, D
Rationale: Late decelerations, caused by reduced placental blood flow, indicate fetal hypoxia and require intervention.
The nurse is caring for a 2-hour-old infant at risk for cold stress. Which of the following assessment findings would support an early finding of cold stress?
- A. shivering
- B. hyperglycemia
- C. tachycardia
- D. bradypnea
Correct Answer: C
Rationale: Tachycardia is an early sign of cold stress as the infant attempts to increase metabolism to maintain body temperature.
When educating an adolescent diagnosed with bacterial conjunctivitis about how to prevent the spread of their infection, which of the following points should you include?
- A. Do not share towels or washcloths with family members.
- B. Stay home from school until they have taken antibiotics for 48 hours.
- C. Apply a warm compress to lessen any irritation.
- D. Throw out the contact lenses and get new ones.
- E. Perform hand hygiene, especially prior to touching face or eyes
Correct Answer: A, D, E
Rationale: Not sharing towels, discarding contact lenses, and hand hygiene prevent the spread of bacterial conjunctivitis. Warm compresses are not recommended, and 24 hours of antibiotics is typically sufficient for returning to school.
The nurse in the outpatient clinic is caring for a 33-year-old female.
Item 1 of 1
Nurses' Note
1435: Client reports vaginal discharge that is malodorous x 3 days. The client reports that the discharge is thin, green, and yellow. She reports being sexually active with multiple partners without any protection. She denies any dysuria, dyspareunia, fevers, chills, or fatigue. The client is alert and oriented to person, place, and time. Reports no pain. Lung sounds are clear, with a regular breathing pattern. Active bowel sounds in all quadrants. Peripheral pulses were 2+ and regular—no peripheral edema. Skin is warm and moist. Vital signs: T 98° F (36.7° C), P 72, RR 18, BP 132/76, pulse oximetry reading 98% on room air.
Complete the following sentences by choosing from the lists of options. The client is demonstrating signs and symptoms of ___ To confirm this diagnosis, the nurse anticipates a physician's order for...........
- A. syphilis
- B. trichomoniasis
- C. urolithiasis
- D. human immunodeficiency virus (HIV)
- E. wet mount microscopy
- F. RPR (rapid plasma reagin)
- G. HIV p24 antigen
Correct Answer: B, E
Rationale: The client's symptoms of malodorous, thin, green, and yellow vaginal discharge are characteristic of trichomoniasis, a sexually transmitted infection caused by Trichomonas vaginalis. Wet mount microscopy is the appropriate diagnostic test to confirm this by identifying the parasite.
The nurse in the emergency department (ED) is caring for a 64-year-old male client.
Item 4 of 6
Nurses' Notes
1742: Client arrives at the emergency department via emergency medical services (EMS). He was skiing and crashed into a post and fell to the ground. Ski patrol assessed the client, and the client was confused and had no memory of the crash. Ski patrol reports that he was wearing a helmet and had a loss of consciousness for an unknown amount of time. On assessment, the client was alert and oriented to place and time but did not recall the events leading up to hospitalization, specifically the ski crash. Client states, “My head really hurts and I'm dizzy.” Reporting aching pain rated 8/10 on the Numerical Pain Scale. Reddish contusion on the client's forehead. Pupils were 2+, equal, and sluggishly reactive to light. Glasgow Coma Scale 14. Nose is midline and symmetrical. His speech was clear and articulate. Full range of motion in all extremities observed. Clear lung fields bilaterally. Radial pulse 2+ and irregular. Normoactive bowel sounds in all quadrants. No abdominal distention or pain. Vital signs: T 97.8° F (36.6° C), P 85, RR 15, BP 124/82, pulse oximetry reading 98% on room air. The client has a medical history of essential hypertension, generalized anxiety disorder, atrial fibrillation, and chronic back pain.
Diagnostic Results
Head and Neck Computed Tomography (CT) Scan with Contrast
1831: Bilateral convexity subarachnoid hemorrhage over the right frontal lobe.
Laboratory Results
1849: Hemoglobin (Hgb) 14 g/dL [Male: 14-18 g/dL Female: 12-16 g/dL]
Hematocrit (Hct) 42% [Male: 42-52% Female: 37-47%]
International Normalized Ratio (INR) 3.8 [0.9-1.2]
Platelets 140,000 mm3 [150,000-400,00 mm3]
Home medications
• multivitamin (MVI) 1 tablet PO daily
• fluoxetine 20 mg PO daily
• biotin 100 mcg PO daily
• pantoprazole 40 mg PO daily
• warfarin 2.5 mg PO daily
• diltiazem controlled-release 120 mg PO daily
The nurse reviews the diagnostic and laboratory results. For each potential nursing intervention, click to specify whether the Nurses' Notes intervention is indicated or not indicated for the care of the client.
- A. obtain an order for serum type and screen
- B. obtain a prescription for protamine sulfate
- C. perform neurological assessments every 15 minutes
- D. obtain a prescription for andexanet
- E. obtain a prescription to transfuse platelets
- F. obtain a prescription for ketorolac
- G. monitor the client for signs and symptoms of increased intracranial pressure
Correct Answer: A, C, D, G (indicated); B, E, F (not indicated)
Rationale: Indicated: Serum type and screen for potential transfusion, frequent neurological assessments, andexanet for warfarin reversal, and monitoring for increased intracranial pressure due to subarachnoid hemorrhage. Not indicated: Protamine sulfate (for heparin, not warfarin), platelet transfusion (platelets mildly low), ketorolac (contraindicated due to bleeding risk).