Nokea
Which intervention would you expect to render to the client in a sickle cell anemia crisis?
- A. The administration of a thrombolytic medication
- B. The administration of hydroxyurea
- C. Placing the client in the Trendelenburg position
- D. Placing the client in the lithotomy position
Correct Answer: B
Rationale: Hydroxyurea is used in sickle cell anemia to reduce the frequency of crises by increasing fetal hemoglobin, which helps prevent sickling of red blood cells.
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A client with a history of gout is prescribed febuxostat (Uloric). The nurse should monitor the client for which of the following adverse effects?
- A. Hepatotoxicity.
- B. Hypoglycemia.
- C. Hypertension.
- D. Weight gain.
Correct Answer: A
Rationale: Febuxostat can cause hepatotoxicity, requiring liver function monitoring.
The nurse is teaching a client with asthma about the use of a peak flow meter. Which of the following instructions should be included?
- A. Use the meter only when symptoms are present.
- B. Record the highest of three readings.
- C. Clean the meter with soap and water weekly.
- D. Blow into the meter as slowly as possible.
Correct Answer: B, C
Rationale: Recording the highest of three readings ensures accuracy, and cleaning the meter weekly prevents contamination.
The A, B, C, and Ds of a complete and comprehensive nutritional assessment includes:
- A. Assessment data, biochemical data, clinical data and dietary data
- B. Ancestral cultural data, biochemical data, clinical data and dietary data
- C. Anthropometric data, biological data, chemical data and dietary data
- D. Anthropometric data, biochemical data, clinical data and dietary data
Correct Answer: D
Rationale: A comprehensive nutritional assessment includes Anthropometric data (e.g., height, weight), Biochemical data (e.g., lab values), Clinical data (e.g., physical signs), and Dietary data (e.g., intake history).
A client tells the nurse that she has had sexual contact with someone whom she suspects has genital herpes. Which of the following instructions should the nurse give the client in response to this information?
- A. Anticipate lesions within 25 to 30 days.
- B. Continue sexual activity unless lesions are present.
- C. Report any difficulty urinating.
- D. Drink extra fluids to prevent lesions from forming.
Correct Answer: C
Rationale: Difficulty urinating can indicate herpes-related urinary retention, a serious complication requiring medical attention.
The nurse is beginning the shift and is now responsible for the following clients on the postpartum unit and has not yet made rounds on the clients. Additionally, the nurse is responsible for three other clients who are currently listed as stable. The nurse will also be getting a new admission in 15 minutes. For the best utilization of time and client safety, the nurse should make rounds on which of the following clients first?
- A. The three clients who are reported to be stable.
- B. The mother with a 4-hour-old infant with initial blood glucose of 33 mg\dL and now at 15 mg/dL.
- C. A mother who had a spontaneous vaginal delivery (SVD) client and received methylergonovine maleate (Methergine) 1 hour ago for increased bleeding.
- D. A mother with a 3-day-old who had a bilirubin level of 13 mg\dL 30 minutes ago, and is now in a 'bili blanket' at the mother's bedside.
Correct Answer: B
Rationale: The infant with a blood glucose of $15 \mathrm{mg} / \mathrm{dL}$ is critically low, indicating severe hypoglycemia, which requires immediate intervention to prevent neurological damage.