Nokea
Which statement made by the parent of a child newly diagnosed with sickle cell anemia indicates a need for more teaching?
- A. We are going to the mountains for our vacation this year.'
- B. It's a good thing she likes to drink juices.'
- C. If she needs something for pain, I will give her baby acetaminophen.'
- D. I will make sure that she doesn't get chilled when it is cold outside.'
Correct Answer: A
Rationale: High altitudes, like mountains, have lower oxygen levels, which can precipitate a sickle cell crisis, indicating a need for more teaching. Drinking juices, using acetaminophen, and avoiding chills are appropriate.
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The client diagnosed with anemia has an Hb of 6.1 g/dL. Which complication should the nurse assess for?
- A. Decreased pulmonary functioning.
- B. Impaired muscle functioning.
- C. Congestive heart failure.
- D. Altered gastric secretions.
Correct Answer: C
Rationale: Severe anemia (Hb 6.1) reduces oxygen delivery, straining the heart and risking CHF (C). Pulmonary (A), muscle (B), and gastric (D) issues are less direct.
When reviewing the client’s medical record, the experienced nurse discovers that the client’s breast cancer is staged as T4 N3 M1. Which comment made by the experienced nurse to the new nurse is correct?
- A. “This client has a 3-cm breast tumor that has spread to only one lymph node.”
- B. “The TNM system is used to classify solid tumors by size and degree of spread.”
- C. “The higher the number in the TNM system, the better the chances are for a cure.”
- D. “This TNM system helps to classify tumors as either well- or poorly differentiated.”
Correct Answer: B
Rationale: A. The T4 N3 M1 indicates that the client’s primary tumor is very large, involves 3 lymph nodes, with distant metastasis (T is the size and extent and ranges from 1-4; N is number of nodes involved, and M1 indicates metastasis). B. This statement is correct. The tumor-node-metastasis (TNM) system classifies solid tumors by size and degree of spread. It is an international system that allows comparison of statistics among cancer centers. C. A higher number means that a more serious situation exists. D. A different rating system is used to define the cell types of tumors as well differentiated (closely resembles normal tissue) or poorly differentiated (tumor that contains some normal cells, but most cells are abnormal).
The charge nurse in the intensive care unit is making client assignments. Which client should the charge nurse assign to the graduate nurse who has just finished the three (3)-month orientation?
- A. The client with an abdominal peritoneal resection who has a colostomy.
- B. The client diagnosed with pneumonia who has acute respiratory distress syndrome.
- C. The client with a head injury developing disseminated intravascular coagulation.
- D. The client admitted with a gunshot wound who has an H&H of 7 and 22.
Correct Answer: A
Rationale: Colostomy care (A) is stable and suitable for a new graduate. ARDS (B), DIC (C), and severe anemia (D) are critical, requiring experienced care.
Which statement is the scientific rationale for infusing a unit of blood in less than four (4) hours?
- A. The blood will coagulate if left out of the refrigerator for greater than four (4) hours.
- B. The blood has the potential for bacterial growth if allowed to infuse longer.
- C. The blood components begin to break down after four (4) hours.
- D. The blood will not be affected; this is a laboratory procedure.
Correct Answer: B
Rationale: Blood must infuse within 4 hours (B) to minimize bacterial growth risk. Coagulation (A) is not primary, components (C) degrade minimally, and lab procedure (D) is incorrect.
The nurse is caring for a client in a sickle cell crisis. Which is the pain regimen of choice to relieve the pain?
- A. Frequent aspirin (acetylsalicylic acid) and a nonnarcotic analgesic.
- B. Motrin (ibuprofen), a nonsteroidal anti-inflammatory drug (NSAID), prn.
- C. Demerol (meperidine), a narcotic analgesic, every four (4) hours.
- D. Morphine, a narcotic analgesic, every two (2) to three (3) hours prn.
Correct Answer: D
Rationale: Morphine PRN (D) is preferred for severe SCA crisis pain, titrated to relief. Aspirin (A) and ibuprofen (B) are insufficient and risk bleeding, and meperidine (C) risks seizures.