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The parents of a child who has been diagnosed with sickle cell anemia ask why their child experiences pain. What is the most likely cause of the pain?
- A. Inflammation of the vessels
- B. Obstructed blood flow
- C. Overhydration
- D. Stress-related headaches
Correct Answer: B
Rationale: The correct answer is B: Obstructed blood flow. In sickle cell anemia, the sickle-shaped red blood cells can clump together, obstructing blood flow in the vessels. This obstruction leads to tissue hypoxia (lack of oxygen) and necrosis, causing pain. Choice A, inflammation of the vessels, is not the primary cause of pain in sickle cell anemia. Choice C, overhydration, is unrelated to the pathophysiology of sickle cell anemia. Choice D, stress-related headaches, is not a characteristic symptom of sickle cell anemia.
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The nurse is teaching a client with glomerulonephritis about self-care. Which dietary recommendations should the nurse encourage the client to follow?
- A. Increase intake of high-fiber foods, such as bran cereal
- B. Restrict protein intake by limiting meats and other high-protein foods.
- C. Limit oral fluid intake to 500ml per day
- D. Increase intake of potassium-rich foods such as bananas and cantaloupe.
Correct Answer: B
Rationale: The correct answer is B: Restrict protein intake by limiting meats and other high-protein foods. In glomerulonephritis, reducing protein intake helps to lower the workload on the kidneys, as excessive protein can lead to increased production of waste products that the kidneys must filter. This restriction can help prevent further damage to the kidneys. Choices A, C, and D are incorrect because: A) Increasing high-fiber foods like bran cereal is beneficial for other conditions but not specific to glomerulonephritis. C) Limiting oral fluid intake to 500ml per day is not appropriate as fluid restrictions are usually individualized based on the client's condition and kidney function. D) Increasing potassium-rich foods like bananas and cantaloupe may not be suitable for all clients with glomerulonephritis, as potassium levels can be affected in kidney disease and individual needs may vary.
Which instruction should be included in the discharge teaching plan for a client who has had a cataract extraction today?
- A. Use a metal eye shield on the operative eye during the day.
- B. Administer eye ointment after applying eye drops.
- C. Light housekeeping is safe to do, but avoid heavy lifting.
- D. Refrain from sexual activities until follow-up appointment.
Correct Answer: C
Rationale: The correct instruction to include in the discharge teaching plan for a client who has had a cataract extraction is that light housekeeping is safe to do, but heavy lifting should be avoided to prevent increased intraocular pressure. Choice A is incorrect as the eye shield is usually worn at night to protect the eye. Choice B is incorrect as eye ointment is usually applied after eye drops to avoid washing away the ointment. Choice D is incorrect as sexual activities should be avoided until the follow-up appointment to prevent complications.
The nurse is teaching a client how to collect a sputum specimen. Which steps should the nurse instruct the client to follow when collecting sputum?
- A. Breathe deeply, followed by swallowing.
- B. Breathe deeply, followed by spitting into a cup.
- C. Breathe deeply, followed by coughing up the sputum.
- D. Breathe deeply, followed by clearing the throat.
Correct Answer: C
Rationale: The correct answer is to instruct the client to breathe deeply followed by coughing up the sputum. This method ensures that the specimen is collected from the lower respiratory tract and is not contaminated by saliva. Choice A (swallowing) does not result in sputum collection, while choice B (spitting into a cup) may lead to saliva contamination. Choice D (clearing the throat) is not an effective way to collect sputum as it may involve getting rid of saliva, not sputum.
The healthcare provider prescribes Cytovene 375 mg every 12 hours to infuse over 90 minutes. The pharmacy delivers Cytovene 375 mg in a 150 mL IV bag. How many ml/hour should the nurse program the infusion pump?
- A. 50 ml/hour.
- B. 75 ml/hour.
- C. 100 ml/hour.
- D. 125 ml/hour.
Correct Answer: C
Rationale: To infuse 150 mL over 90 minutes, the pump should be set to 100 ml/hour (150 mL / 1.5 hours). This rate ensures that the medication is delivered at the proper rate as prescribed. Choices A, B, and D are incorrect because they do not reflect the correct calculation based on the volume of the IV bag and the infusion duration provided in the question.
A client with urolithiasis is preparing for discharge after lithotripsy. Which intervention should the nurse include in the client's postoperative discharge instructions?
- A. Report when hematuria becomes pink-tinged
- B. Use incentive spirometer
- C. Restrict physical activities
- D. Monitor urinary stream for a decrease in output
Correct Answer: D
Rationale: After lithotripsy, monitoring the urinary stream for a decrease in output is essential to identify any potential complications such as urinary retention or obstruction. Reporting pink-tinged hematuria is important, but monitoring the urinary stream for a decrease in output takes precedence as it directly assesses renal function and potential complications. Using an incentive spirometer is not directly related to post-lithotripsy care. Restricting physical activities may be necessary initially but is not the priority compared to monitoring urinary output.