Nokea
Which nursing intervention would be of highest priority when caring for a patient admitted in sickle cell vaso-occlusive crisis?
- A. Starting intravenous normal saline
- B. Applying oxygen
- C. Applying heat to the affected joints
- D. Administering pain medication
Correct Answer: D
Rationale: In sickle cell vaso-occlusive crisis severe pain results from blocked blood vessels. Administering pain medication is the highest priority to relieve acute discomfort and improve patient comfort. While IV fluids and oxygen are important pain management is the most urgent need.
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The family member of a child scheduled for heart surgery states, 'I just don't understand this open-heart or closed-heart business. I'm so confused! Can you help me understand it?' The nurse explains that patent ductus arteriosus repair is:
- A. Open-heart surgery. The child will be placed on a heart-lung machine while the surgery is being performed.
- B. Closed-heart surgery. It does not require that the child be placed on the heart-lung machine while the surgery is being performed.
- C. A pediatric version of the coronary artery bypass graft surgery performed on adults. It is an open-heart surgery.
- D. A pediatric version of percutaneous transluminal coronary angioplasty performed on adults. It is a closed-heart surgery.
Correct Answer: B
Rationale: Patent ductus arteriosus repair is a closed-heart procedure. The client is not placed on a heart-lung machine. Patent ductus arteriosus is a ductus arteriosus that does not close shortly after birth but remains patent. Repair is a closed-heart procedure involving ligation of the patent ductus arteriosus. Coronary artery bypass graft surgery is an open-heart surgical procedure in which blocked coronary arteries are bypassed using vessel grafts. Percutaneous transluminal coronary angioplasty is a closed-heart procedure that improves coronary blood flow by increasing the lumen size of narrowed vessels.
A child with celiac disease is being discharged from the hospital. The mother demonstrates knowledge of nutritional needs of her child when she is able to state the foods which are included in a:
- A. Lactose-restricted diet
- B. Gluten-restricted diet
- C. Phenylalanine-restricted diet
- D. Fat-restricted diet
Correct Answer: B
Rationale: A lactose-restricted diet is prescribed for children with lactose intolerance or diarrhea. A gluten-restricted diet is the diet for children with celiac disease. A phenylalanine-restricted diet is prescribed for children with phenylketonuria. A fat-restricted diet is prescribed for children with disorders of the liver, gallbladder, or pancreas.
A client is admitted to the labor unit. On vaginal examination, the presenting part in a cephalic presentation was at station plus two. Station +2 means that the:
- A. Presenting part is 2 cm above the level of the ischial spines
- B. Biparietal diameter is at the level of the ischial spines
- C. Presenting part is 2 cm below the level of the ischial spines
- D. Biparietal diameter is 5 cm above the ischial spines
Correct Answer: C
Rationale: Station +2 means the presenting part is 2 cm below the ischial spines, indicating descent in the pelvis.
A postpartum client complains of rectal pressure and severe pain in her perineum; this may be indicative of:
- A. Afterbirth pains
- B. Constipation
- C. Cystitis
- D. A hematoma of the vagina or vulva
Correct Answer: D
Rationale: Afterbirth pains are a common complaint in the postpartum client, but they are located in the uterus. Constipation may cause rectal pressure but is not usually associated with 'severe pain.' Cystitis may cause pain, but the location is different. Hematomas are frequently associated with severe pain and pressure. Further assessments are indicated for this client.
A client with a history of pulmonary embolism is admitted with complaints of chest pain. The nurse should give priority to:
- A. Administering anticoagulants
- B. Monitoring respiratory status
- C. Administering pain medication
- D. Monitoring blood pressure
Correct Answer: A
Rationale: Anticoagulants prevent further clot formation in pulmonary embolism, making them the priority to reduce complications.