Nokea
The nurse should instruct a young female adult with sickle cell anemia to do which of the following? Select all that apply.
- A. Drink plenty of fluids when outside in hot weather.
- B. Avoid travel to cities where the oxygen level is lower.
- C. Compare that since she is homozygous for HbS, she carries the sickle cell trait.
- D. Know that pregnancy with sickle cell disease increases the risk of a crisis.
- E. Avoid flying on commercial airlines.
Correct Answer: A,B,D
Rationale: Sickle cell anemia requires preventive measures to avoid crises. Drinking fluids in hot weather prevents dehydration, a trigger for sickling. Avoiding high-altitude cities reduces hypoxia risk, another trigger. Pregnancy increases the risk of crises due to increased metabolic demands. The statement about being homozygous for HbS is incorrect, as it indicates sickle cell disease, not the trait. Flying on commercial airlines is generally safe if the client is stable.
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What is the primary goal collaboratively established by the client with Parkinson's disease, nurse, and physical therapist?
- A. To maintain joint flexibility.
- B. To build muscle strength.
- C. To improve muscle endurance.
- D. To reduce ataxia.
Correct Answer: A
Rationale: Maintaining joint flexibility is the primary goal to prevent contractures and maintain mobility in Parkinson's disease. Strength, endurance, and ataxia (less common in Parkinson's) are secondary.
Following a laryngectomy, the nurse notices that the client has saliva collecting beneath the skin flaps. This finding is indicative of which of the following?
- A. Skin necrosis.
- B. Carotid artery rupture.
- C. Stomal Stenosis.
- D. Development of a fistula.
Correct Answer: D
Rationale: Saliva collecting beneath skin flaps post-laryngectomy indicates a fistula, where saliva leaks from the pharynx or esophagus into surrounding tissues, requiring immediate attention.
After an inguinal herniorrhaphy, the nurse should assess the client carefully for which of the following likely complications?
- A. Pneumonia.
- B. Deep vein thrombosis.
- C. Paralytic ileus.
- D. Urine retention.
Correct Answer: D
Rationale: Urine retention is a likely complication after inguinal herniorrhaphy due to anesthesia, pain, or surgical manipulation near the bladder. Pneumonia, deep vein thrombosis, and paralytic ileus are less specific to this surgery. CN: Physiological adaptation; CL: Analyze
The nurse is assessing the urine of a client who has had an ileal conduit and notes that the urine is yellow with a moderate amount of mucus. Based on the data, the nurse should?
- A. Change the appliance bag.
- B. Notify the physician.
- C. Obtain a urine specimen for culture.
- D. Encourage a high fluid intake.
Correct Answer: D
Rationale: Yellow urine with moderate mucus is normal for an ileal conduit due to intestinal segment use. Encouraging high fluid intake prevents complications like calculi or infection.
The nurse is caring for a client receiving a continuous infusion of isotonic fluids and observes infiltration at the vascular access device. The nurse should take which action?
- A. Reduce the infusion rate and elevate the affected extremity.
- B. Stop the infusion and remove the intravenous (IV) catheter.
- C. Stop the infusion and reposition the intravenous (IV) catheter into the vein.
- D. Reduce the infusion rate and apply a warm compress to the intravenous (IV) site.
Correct Answer: B
Rationale: Infiltration requires stopping the infusion and removing the catheter to prevent further tissue damage.