Nokea
Which statement by the client regarding sickle cell disease indicates a need for further teaching?
- A. I should avoid strenuous exercise.
- B. I can enjoy one glass of red wine per day.
- C. I will avoid cigarettes and all tobacco products.
- D. I should avoid traveling to places at high altitudes such as Denver.
Correct Answer: B
Rationale: Alcohol, including red wine, can cause dehydration and increase the risk of sickle cell crisis, so it should be avoided. Other statements are correct.
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Skeletal traction is applied to the right femur of a client injured in a fall. The primary purpose of the skeletal traction is to:
- A. Realign the tibia and fibula
- B. Provide traction on the muscles
- C. Provide traction on the ligaments
- D. Realign femoral bone fragments
Correct Answer: D
Rationale: Skeletal traction for a femoral injury aims to realign femoral bone fragments, promoting proper healing and preventing deformity.
The nurse is caring for a client with an above-the-knee amputation (AKA). To prevent contractures, the nurse should:
- A. Place the client in a prone position 15-30 minutes twice a day
- B. Keep the foot of the bed elevated on shock blocks
- C. Place trochanter rolls on either side of the affected leg
- D. Keep the client's leg elevated on two pillows
Correct Answer: A
Rationale: Prone positioning helps stretch hip flexors, preventing contractures after AKA by maintaining proper alignment.
The nurse is caring for a laboring client who is on an oxytocin infusion. The client experiences seven contractions in a 10-minute time period. The fetal heart rate tracing is a category III. Which action should the nurse take?
- A. discontinue the oxytocin infusion
- B. increase the oxytocin infusion rate
- C. decrease the oxytocin infusion rate by half
- D. reposition the client into a high-Fowler's position
Correct Answer: A
Rationale: A category III fetal heart rate tracing indicates fetal distress, and seven contractions in 10 minutes suggest uterine hyperstimulation. Discontinuing oxytocin is the priority to reduce fetal stress.
The nurse has just administered an IM injection to a client. In which of the following ways should the nurse dispose of the needle?
- A. re-cap the needle and discard it in the nearest puncture-resistant container
- B. break the needle and discard it in the nearest puncture-resistant container
- C. discard the needle in a puncture-resistant container in the central medication area
- D. discard the needle in a puncture-resistant container in the client's room
Correct Answer: D
Rationale: Needles should be disposed of immediately in a puncture-resistant container in the client’s room to minimize sharps injury risk.
The nurse is teaching the parents of an infant with osteogenesis imperfecta. The nurse should explain the need for:
- A. Additional calcium in the infant's diet
- B. Careful handling to prevent fractures
- C. Providing extra sensorimotor stimulation
- D. Frequent testing of visual function
Correct Answer: B
Rationale: Osteogenesis imperfecta causes brittle bones, so careful handling is critical to prevent fractures in infants with this condition.