Nokea
The nurse is reviewing the serum laboratory test results for a client with a diagnosis of sickle cell anemia. Which parameter should the nurse anticipate will be elevated?
- A. Sodium
- B. Hemoglobin-S
- C. Hemoglobin A1c
- D. Prothrombin time
Correct Answer: B
Rationale: Sickle cell anemia is a severe anemia that affects African Americans predominantly and is characterized by sickled hemoglobin, or HgbS. The client must have two abnormal genes yielding hemoglobin-S to have sickle cell anemia. A client could have sickle cell trait by carrying one hemoglobin-A gene and one hemoglobin-S gene; then, the client has a less severe form of sickle cell anemia. The remaining options are unrelated to sickle cell anemia.
You may also like to solve these questions
The nurse manager is developing a 'read-back' procedure to reduce medication administration errors. Which of the following are purposes of the 'read-back' requirement? Select all that apply.
- A. To prohibit orders and test results from being communicated verbally or by telephone.
- B. To ensure that orders and test results that are communicated verbally or by telephone are clear to the receiver of the information.
- C. To make sure that orders and test results that are communicated verbally or by telephone are confirmed by the individual giving the information.
- D. To minimize the risk of non-authorized personnel from giving orders which are communicated verbally or by telephone.
- E. To encourage the use of electronic medical records.
Correct Answer: B,C,D
Rationale: Read-back ensures clarity, confirmation, and authorized communication of verbal orders, reducing errors. It does not prohibit verbal orders or mandate electronic records.
A postpartum client is experiencing heavy lochia 3 days after delivery. Which action should the nurse take first?
- A. Massage the fundus
- B. Administer oxytocin as ordered
- C. Encourage the client to ambulate
- D. Notify the physician
Correct Answer: A
Rationale: Heavy lochia may indicate uterine atony. Massaging the fundus is the first step to promote uterine contraction and reduce bleeding before escalating to other interventions.
A client demonstrating unstable ventricular tachycardia (VT) loses consciousness and becomes pulseless after an initial treatment with a dose of lidocaine intravenously. Which item should the nurse caring for the client immediately obtain?
- A. A pacemaker
- B. A defibrillator
- C. A second dose of lidocaine
- D. An electrocardiogram machine
Correct Answer: B
Rationale: For the client with VT who becomes pulseless, the primary health care provider or qualified advanced cardiac life support personnel immediately defibrillate the client. In the absence of this equipment, cardiopulmonary resuscitation is initiated immediately. None of the remaining options are items that are needed immediately to manage this situation.
A multigravid client at 34 weeks’ gestation who is leaking amniotic fl uid has just been hospitalized with a diagnosis of preterm premature rupture of membranes and preterm labor. The client’s contractions are 20 minutes apart, lasting 20 to 30 seconds. Her cervix is dilated to 2 cm. The nurse reviews the physician orders (see chart). Which of the following orders should the nurse initiate first?
- A. Initiate fetal and contraction monitoring
- B. Start the intravenous infusion
- C. Obtain the urine specimen
- D. Administer betamethasone
Correct Answer: A
Rationale: The nurse should initiate fetal and contraction monitoring for this client upon arrival to the unit. This gives the nurse data regarding changes in fetal and maternal contraction status before completing the other orders. Next, the betamethasone would be given to begin the maturation process for the fetal lungs. Next, the nurse should start an intravenous infusion to provide a line for immediate intravenous access, if needed, and provide hydration for the client. The nurse should obtain the urine specimen prior to administering any antibiotic therapy, if ordered.
What ethical principle below is accurately paired with a way that ethical principle is applied into nursing practice?
- A. Justice: Equally dividing time and other resources among a group of clients
- B. Beneficence: Doing no harm during the course of nursing care
- C. Veracity: Fully answering the client's questions without any withholding of information
- D. Fidelity: Upholding the American Nurses Association's Code of Ethics
Correct Answer: C
Rationale: Veracity is accurately paired with fully answering the client's questions without withholding information, as it emphasizes truthfulness in nursing practice. Justice involves fair treatment, not just equal time ; Beneficence involves promoting good, not just avoiding harm ; Fidelity is about keeping promises, not specifically the ANA Code .