Nokea
What is the primary goal of care for a client diagnosed with sickle cell anemia?
- A. The client will call the healthcare provider if feeling ill.
- B. The client will be compliant with the medical regimen.
- C. The client will live as normal a life as possible.
- D. The client will verbalize understanding of treatments.
Correct Answer: C
Rationale: The correct answer is C: 'The client will live as normal a life as possible.' For a client with sickle cell anemia, the primary goal of care is to promote a good quality of life by managing symptoms, preventing crises, and enhancing overall well-being. Option A is incorrect as it focuses on a specific action rather than the overall goal of care. Option B is important but not the primary goal; compliance is a means to achieve better health outcomes. Option D is also important but does not address the holistic approach of helping the client maintain a normal lifestyle despite their condition.
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When palpating the client's neck for lymphadenopathy, where should the nurse position himself?
- A. At the client's back
- B. At the client's right side
- C. At the client's left side
- D. In front of a sitting client
Correct Answer: D
Rationale: When palpating the client's neck for lymphadenopathy, the nurse should position himself in front of a sitting client. This positioning allows for easier access to the neck area and better visualization of any swelling or abnormalities in the lymph nodes. Being in front of the client ensures proper alignment and comfort for both the nurse and the client during the assessment. Choices A, B, and C are incorrect because positioning at the client's back or sides would make it challenging to adequately palpate the neck area and assess for lymphadenopathy.
A patient taking anticoagulants should be cautious about consuming which type of food?
- A. High-protein foods
- B. High-fiber foods
- C. High-vitamin K foods
- D. High-calcium foods
Correct Answer: C
Rationale: The correct answer is C: High-vitamin K foods. Foods high in vitamin K can interfere with the effectiveness of anticoagulants. Vitamin K plays a crucial role in blood clotting, so consuming high amounts of it can counteract the anticoagulant effects. Choices A, B, and D are incorrect as they do not directly interfere with the action of anticoagulants.
For which client situation would a consultation with a rapid response team (RRT) be most appropriate?
- A. 45-year-old; 2 years post kidney transplant; second hospital day for treatment of pneumonia; no urine output for 6 hours; temperature 101.4°F; heart rate of 98 beats per minute; respirations 20 breaths per minute; blood pressure 88/72 mm Hg; is restless
- B. 72-year-old; 24 hours after removal of a chest tube that was used to drain pleural fluid (effusion); temperature 97.8°F; heart rate 92 beats per minute; respirations 28 breaths per minute; blood pressure 132/86 mm Hg; anxious about going home
- C. 56-year-old fourth hospital day after a coronary artery bypass procedure; sore chest; pain with walking temperature 97°F; heart rate 84 beats per minute; respirations 22 breaths per minute; blood pressure 87/72 mm Hg; bored with hospitalization.
- D. 86-year-old; 48 hours postoperative repair of a fractured hip (nail inserted; alert; oriented; using patient-controlled analgesia (PCA) pump; temperature 96.8°F; heart rate 60 beats per minute; respirations 16 breaths per minute; blood pressure 90/62 mm Hg; talking with daughter.
Correct Answer: A
Rationale: A consultation with a Rapid Response Team (RRT) is most appropriate for the 45-year-old client described in Choice A. This client is 2 years post kidney transplant, presenting with no urine output for 6 hours, a temperature of 101.4°F, heart rate of 98 beats per minute, respirations of 20 breaths per minute, and a blood pressure of 88/72 mm Hg, along with restlessness. These clinical signs are indicative of possible acute renal failure and sepsis, requiring immediate intervention by the rapid response team. Choices B, C, and D do not present the same level of urgency and severity of symptoms as the client in Choice A, making them less appropriate for consultation with the RRT.
A client with type 1 diabetes is diagnosed with diabetic ketoacidosis and initially treated with intravenous fluids followed by an IV bolus of regular insulin. The nurse anticipates that the practitioner will prescribe a continuous infusion of insulin of:
- A. Novolin L insulin
- B. Novolin R insulin
- C. Novolin N insulin
- D. Novolin U insulin
Correct Answer: B
Rationale: The correct answer is Novolin R (Regular insulin) because it is used for continuous infusion to treat diabetic ketoacidosis. Novolin R has a rapid onset of action, making it suitable for this acute situation. Novolin L insulin (Choice A) is not typically used for continuous infusion in diabetic ketoacidosis. Novolin N insulin (Choice C) is an intermediate-acting insulin and is not ideal for rapid correction needed in diabetic ketoacidosis. Novolin U insulin (Choice D) is an ultra-long-acting insulin and is not appropriate for the immediate correction required in this scenario.
Which hospital level is a 296-bed facility that is staffed and equipped to provide care for all categories of patients?
- A. FSB
- B. CSH
- C. GH
- D. FH
Correct Answer: C
Rationale: The correct answer is "GH" (General Hospital), which is a 296-bed facility providing comprehensive care for all categories of patients. Choice A, FSB, is incorrect as it does not denote a hospital level. Choice B, CSH, is incorrect as it does not specify a 296-bed facility. Choice D, FH, is incorrect as it does not indicate a hospital level or capacity.