Question

A nurse is caring for a client who presents to the emergency room in sickle cell crisis. Which of the following medications should the nurse anticipate administering?

Answer 1

Correct Answers:

Pain medications

Rationale :

🔷 Pain medications are the PRIORITY because sickle cell crisis causes severe vaso-occlusive pain due to blocked blood vessels.

🔷 Opioids are required to relieve ischemic pain and reduce metabolic demand.

🔷 Pain control improves oxygenation by reducing stress-induced hypoxia.

🔷 Adequate analgesia prevents worsening of the crisis and improves patient mobility.

🔷 Uncontrolled pain increases sympathetic response, worsening sickling.

Diuretics

🔷 Do not relieve vaso-occlusive pain or improve circulation.

🔷 They may worsen dehydration, which increases sickling.

Thyroid replacement medications

🔷 No relation to sickle cell pathology.

🔷 Used for hypothyroidism, not pain crises.

Laxatives

🔷 Treat constipation, not a sickle cell crisis.

🔷 Provide no benefit for vaso-occlusion.

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Answer 2

Correct Answers:

The burned area is pink in color with blisters present.

Rationale :

💠 Deep partial-thickness burns involve the dermis and present as pink to red, with moist appearance, blisters, and moderate pain.

💠 Sensation may be decreased but pain is still present.

💠 Blistering reflects intact vasculature and partial dermal damage.

💠 These burns typically heal in 2–6 weeks with possible scarring.

💠 The color and blister pattern differentiate them from superficial and full-thickness burns.

Black area, pain absent

💠 Indicates full-thickness burn, with nerve destruction.

Red area with eschar

💠 Eschar suggests full-thickness, not partial thickness.

Yellow with severe edema

💠 Yellow, dry appearance suggests third-degree or chemical burns.

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Answer 3

Correct Answers:

Review the client's electrolyte values.

Rationale :

🟦 Acute UC flare causes severe diarrhea, leading to electrolyte imbalance, especially low sodium and potassium.

🟦 Electrolyte abnormalities can cause arrhythmias, dehydration, and hemodynamic instability.

🟦 Identifying imbalances early guides urgent interventions such as fluid replacement.

🟦 This is a physiologic safety priority, which comes before history or psychosocial assessment.

🟦 The nurse must assess life-threatening problems before non-urgent concerns.

Obtain dietary history

🟦 Appropriate but NOT urgent during an acute flare.

Investigate emotional concerns

🟦 Psychosocial needs are important but NOT priority in acute instability.

Check perianal skin integrity

🟦 Important, but electrolyte issues take precedence because they affect survival.

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Answer 4

Correct Answers:

Do not apply heat to the area of irradiation.

Rationale :

🌟 Heat increases vasodilation, worsening radiation-induced skin sensitivity and breakdown.

🌟 Radiation causes fragile, inflamed skin that must be protected from thermal injury.

🌟 Heat can exacerbate erythema, peeling, and burns.

🌟 Best practice recommends gentle care, cool compresses only, and avoiding temperature extremes.

🌟 Preventing irritation promotes healing and prevents treatment delays.

Lubricate with hypoallergenic lotion

🌟 Lotion is allowed BUT not before radiation sessions. The question asks what to include as a rule—heat is the clearest absolute restriction.

Do not wash the area

🌟 Incorrect because patients should gently wash with mild soap.

Use antibiotic ointment

🌟 Not indicated unless there is infection; routine use can worsen irritation.

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Answer 5

Correct Answers:

Troponin

Rationale :

✴️ Troponin is the most sensitive and specific biomarker for cardiac muscle injury.

✴️ It rises within 2–4 hours and stays elevated for days.

✴️ Even small elevations confirm myocardial infarction.

✴️ It differentiates MI from other causes of chest pain.

✴️ It is the gold standard test ordered for suspected MI.

BNP

✴️ BNP evaluates heart failure, not acute MI.

CK (Creatinine kinase)

✴️ CK is not specific to the heart; troponin is superior.

CRP

✴️ Measures inflammation—not diagnostic for MI.

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Answer 6

Correct Answers:

Chocolate

Rationale :

🍫 Chocolate relaxes the lower esophageal sphincter (LES), allowing stomach acid to reflux upward.

🍫 It contains methylxanthines, which lower LES pressure and worsen heartburn and regurgitation.

🍫 Chocolate increases gastric acid secretion, making reflux episodes more severe.

🍫 GERD dietary guidelines consistently warn patients to avoid chocolate as a trigger food.

🍫 Eliminating chocolate reduces frequency and intensity of acid reflux symptoms.

Apples

🍫 Apples are non-acidic and high in fiber, reducing—not worsening—GERD symptoms.

🍫 They do not affect LES tone.

Oatmeal

🍫 Oatmeal is recommended because its high fiber absorbs acid and reduces reflux.

🍫 It stabilizes gastric emptying.

Nonfat milk

🍫 Unlike whole milk, nonfat milk does not increase gastric acid.

🍫 It is soothing and often recommended for GERD.

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Answer 7

Correct Answers:

Red meat and organ meat

Rationale :

🥩 Red meat provides heme iron, the most easily absorbed form (3–5× better than plant iron).

🥩 Organ meats (liver) are extremely rich in iron, helping restore hemoglobin and hematocrit.

🥩 Pregnant clients require increased iron due to expanded blood volume and fetal needs.

🥩 Heme iron absorption is not inhibited by plant phytates or calcium.

🥩 Increasing dietary iron reduces fatigue, pallor, and fetal growth complications.

Whole grain breads

🥩 Contain non-heme iron, which is poorly absorbed and often blocked by phytates.

Fresh fruits

🥩 Provide vitamin C, which helps absorb iron, but are not high in iron themselves.

Milk and cheese

🥩 Dairy contains calcium, which actually inhibits iron absorption.

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Answer 8

Correct Answers:

Protein

Rationale :

🍗 Protein is essential for collagen synthesis, the foundation of wound healing.

🍗 It supports cell regeneration and tissue repair.

🍗 Protein prevents muscle breakdown, improving wound tensile strength.

🍗 Adequate protein boosts immune function, reducing infection risk in open wounds.

🍗 Protein deficiency delays healing and causes poor granulation tissue formation.

Calcium

🍗 Calcium supports bone, not soft-tissue healing.

Vitamin B1 (Thiamine)

🍗 Important for metabolism, but not directly for wound repair.

Vitamin D

🍗 Improves bone and immune health, but not the primary nutrient for wound healing.

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Answer 9

Correct Answers:

"Have you had a recent influenza infection?"

Rationale :

🧬 Guillain-Barré syndrome (GBS) is commonly triggered by a recent viral infection, especially influenza.

🧬 The immune response mistakenly attacks peripheral nerve myelin, causing ascending paralysis.

🧬 Asking about recent infection helps confirm the preceding event that precipitated GBS.

🧬 About ⅔ of clients report an illness 1–4 weeks before symptom onset.

🧬 Identifying the trigger supports accurate diagnosis and early treatment (IVIG, plasmapheresis).

Multivitamin use

🧬 No relationship between vitamins and GBS onset.

Chronic alcohol abuse

🧬 Alcohol can cause neuropathy but not acute ascending paralysis like GBS.

Travel overseas

🧬 Travel is not a known trigger; GBS is immune-related, not environmental exposure.

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Answer 10

Correct Answers:

Check the results of the client's most recent CBC.

Rationale :

🧪 Cisplatin causes bone marrow suppression, leading to anemia → fatigue.

🧪 CBC identifies decreases in hemoglobin, hematocrit, and RBCs, explaining fatigue.

🧪 Monitoring CBC is essential to detect neutropenia and thrombocytopenia as well.

🧪 Fatigue in oncology patients is often due to chemotherapy-induced anemia.

🧪 Evaluating CBC guides whether the client needs dose adjustments or transfusion.

Hypercalcemia evaluation

🧪 Cisplatin is linked to hypomagnesemia and renal toxicity—not hypercalcemia.

Hypersensitivity reaction assessment

🧪 Hypersensitivity presents as rash, dyspnea, not isolated fatigue.

Examine for hepatomegaly

🧪 Liver enlargement is unrelated to cisplatin-induced fatigue.

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QLexNursing

1 :
A nurse is caring for a client who presents to the emergency room in sickle cell crisis. Which of the following medications should the nurse anticipate administering?

2 :
A nurse is assessing a client who is brought to the emergency room with burn injuries. Which of the following findings should the nurse identify a deep partial-thickness burn?

3 :
A nurse is caring for a client who is being admitted for an acute exacerbation of ulcerative colitis. Which of the following actions should the nurs take first?

4 :
A nurse is providing discharge teaching for a client who is postoperative following a simple mastectomy. The client is to begin outpatient radiation therapy the next day. Which of the following instructions about maintaining skin integrity should the nurse include?

5 :
A nurse in the emergency department is caring for a client who is experiencing manifestations of a myocardial infarction (MI). Which of the following laboratory tests should the nurse expect the provider to prescribe?

6 :
A nurse is providing teaching for a client who has a new diagnosis of gastroesophageal reflux disease (GERD). The client asks about foods he should avoid eating. Which of the following foods should the nurse tell him to avoid?

7 :
A nurse is caring for an antepartum client who has iron-deficiency anemia. When teaching the client about nutrition, the nurse should emphasiz the need for an increased intake of which of the following foods?

8 :
A nurse is teaching a client about nutritional requirements necessary to promote wound healing. Which of the following nutrients should thes nurse include in the teaching?

9 :
A nurse is assessing a client who has a suspected diagnosis of Guillain-Barré syndrome (GBS). Which of the following questions should the nurse ask the client?

10 :
A nurse is caring for a client who is receiving cisplatin to treat bladder cancer. After several treatments, the client reports fatigue. Which of the following actions should the nurse take?

QLexNursing

1 : A nurse is caring for a client who presents to the emergency room in sickle cell crisis. Which of the following medications should the nurse anticipate administering?

2 : A nurse is assessing a client who is brought to the emergency room with burn injuries. Which of the following findings should the nurse identify a deep partial-thickness burn?

3 : A nurse is caring for a client who is being admitted for an acute exacerbation of ulcerative colitis. Which of the following actions should the nurs take first?

4 : A nurse is providing discharge teaching for a client who is postoperative following a simple mastectomy. The client is to begin outpatient radiation therapy the next day. Which of the following instructions about maintaining skin integrity should the nurse include?

5 : A nurse in the emergency department is caring for a client who is experiencing manifestations of a myocardial infarction (MI). Which of the following laboratory tests should the nurse expect the provider to prescribe?

6 : A nurse is providing teaching for a client who has a new diagnosis of gastroesophageal reflux disease (GERD). The client asks about foods he should avoid eating. Which of the following foods should the nurse tell him to avoid?

7 : A nurse is caring for an antepartum client who has iron-deficiency anemia. When teaching the client about nutrition, the nurse should emphasiz the need for an increased intake of which of the following foods?

8 : A nurse is teaching a client about nutritional requirements necessary to promote wound healing. Which of the following nutrients should thes nurse include in the teaching?

9 : A nurse is assessing a client who has a suspected diagnosis of Guillain-Barré syndrome (GBS). Which of the following questions should the nurse ask the client?

10 : A nurse is caring for a client who is receiving cisplatin to treat bladder cancer. After several treatments, the client reports fatigue. Which of the following actions should the nurse take?

1 :
A nurse is caring for a client who presents to the emergency room in sickle cell crisis. Which of the following medications should the nurse anticipate administering?

2 :
A nurse is assessing a client who is brought to the emergency room with burn injuries. Which of the following findings should the nurse identify a deep partial-thickness burn?

3 :
A nurse is caring for a client who is being admitted for an acute exacerbation of ulcerative colitis. Which of the following actions should the nurs take first?

4 :
A nurse is providing discharge teaching for a client who is postoperative following a simple mastectomy. The client is to begin outpatient radiation therapy the next day. Which of the following instructions about maintaining skin integrity should the nurse include?

5 :
A nurse in the emergency department is caring for a client who is experiencing manifestations of a myocardial infarction (MI). Which of the following laboratory tests should the nurse expect the provider to prescribe?

6 :
A nurse is providing teaching for a client who has a new diagnosis of gastroesophageal reflux disease (GERD). The client asks about foods he should avoid eating. Which of the following foods should the nurse tell him to avoid?

7 :
A nurse is caring for an antepartum client who has iron-deficiency anemia. When teaching the client about nutrition, the nurse should emphasiz the need for an increased intake of which of the following foods?

8 :
A nurse is teaching a client about nutritional requirements necessary to promote wound healing. Which of the following nutrients should thes nurse include in the teaching?

9 :
A nurse is assessing a client who has a suspected diagnosis of Guillain-Barré syndrome (GBS). Which of the following questions should the nurse ask the client?

10 :
A nurse is caring for a client who is receiving cisplatin to treat bladder cancer. After several treatments, the client reports fatigue. Which of the following actions should the nurse take?