Question

A nurse is assessing a child who is in sickle cell crisis. Which of the following findings should the nurse expect?

Answer 1

Correct Answers:

Pain

Rationale :

💠 Sickle cell crisis causes vascular occlusion from sickled erythrocytes, leading to severe tissue ischemia and pain.

💠 The pain is the hallmark sign, resulting from decreased oxygen delivery to tissues.

💠 Fever may occur but is secondary to infection or inflammation, not the main indicator.

💠 Crisis episodes can be triggered by dehydration, stress, or infection, worsening occlusion and pain.

💠 Nursing care focuses on hydration, oxygen, and pain management to relieve vaso-occlusion.

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Answer 2

Correct Answers:

Administer furosemide.
Measure the client's abdominal girth.
Implement a low-sodium diet.

Rationale :

💎 Furosemide helps reduce ascites and edema by promoting diuresis.

💎 Abdominal girth measurement monitors fluid accumulation from portal hypertension.

💎 Low-sodium diet minimizes water retention, reducing ascites and edema formation.

💎 Weight lifting increases intra-abdominal pressure and should be avoided.

💎 Warfarin is contraindicated due to increased bleeding risk in cirrhosis.

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Answer 3

Correct Answers:

Dispose of the needle uncapped.

Rationale :

🔷 Recapping needles increases risk of needlestick injuries and bloodborne infections like hepatitis C.

🔷 Used needles must be placed directly in a puncture-resistant sharps container.

🔷 The safety principle is to handle sharps minimally after injection.

🔷 Gloves reduce exposure but safe disposal is the priority.

🔷 OSHA and CDC guidelines strictly prohibit recapping of used needles.

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Answer 4

Correct Answers:

Sterile water
Clean gloves
Sterile cotton balls

Rationale :

🔶 Sterile water is used to clean and rinse inner cannula and equipment.

🔶 Clean gloves are used for removing old dressings and non-sterile parts.

🔶 Sterile basin holds sterile solution and cannula during cleaning.

🔶 Sterile cotton-tipped applicators help remove secretions and debris around the stoma.

🔶 Using sterile equipment prevents infection and maintains airway patency.

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Answer 5

Correct Answers:

Vitamin K

Rationale :

🟢 Cirrhosis impairs liver synthesis of clotting factors II, VII, IX, and X, which require vitamin K.

🟢 A prolonged prothrombin time (PT) indicates deficient clotting ability.

🟢 Vitamin K promotes hepatic production of clotting factors to reduce bleeding risk.

🟢 Heparin and warfarin further impair coagulation, so they are contraindicated.

🟢 Correction with Vitamin K helps restore normal hemostasis in mild liver dysfunction.

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Answer 6

Correct Answers:

Amylase

Rationale :

🔵 Amylase and lipase are key pancreatic enzymes that elevate during acute inflammation.

🔵 Levels rise rapidly within hours of pancreatic cell injury.

🔵 Elevated amylase confirms pancreatic tissue destruction.

🔵 Low calcium may develop later due to fat necrosis, not initially elevated.

🔵 Monitoring amylase and lipase helps assess severity and recovery.

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Answer 7

Correct Answers:

Assess the client's respiratory status.

Rationale :

🟣 Assessment determines airway patency, oxygenation, and ventilation effectiveness.

🟣 It identifies causes like mucus obstruction or worsening hypoxia.

🟣 Increasing oxygen without assessment can suppress respiratory drive in COPD.

🟣 The nurse’s first action is always to assess before intervening.

🟣 Findings guide safe management and oxygen adjustment

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Answer 8

Correct Answers:

Rest frequently throughout the day.

Rationale :

🟠 Rest conserves energy and supports hepatic regeneration.

🟠 Activity increases metabolic demands, worsening fatigue.

🟠 Hepatitis causes reduced liver metabolism, so overexertion delays healing.

🟠 High-protein diets worsen hepatic encephalopathy due to ammonia buildup.

🟠 Acetaminophen is hepatotoxic and contraindicated in liver disease.

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Answer 9

Correct Answers:

Stopping the transfusion

Rationale :

🔴 Chills, fever, and back pain indicate a hemolytic transfusion reaction.

🔴 Immediate cessation of transfusion prevents further hemolysis.

🔴 The blood tubing should remain connected to the bag for lab analysis.

🔴 The nurse then notifies the provider and monitors vital signs.

🔴 Early action reduces risk of shock and renal failure.

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Answer 10

Correct Answers:

Provide frequent oral and nares care.

Rationale :

⚪ The tube causes pressure on mucous membranes, leading to irritation and ulceration.

⚪ Frequent oral care maintains comfort and prevents infection.

⚪ Clients cannot swallow or talk easily, increasing dryness risk.

⚪ Keeping the tube secure and clean prevents dislodgement or aspiration.

⚪ Supine position or ambulation may displace the tube and worsen bleeding.

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QLexNursing

1 :
A nurse is assessing a child who is in sickle cell crisis. Which of the following findings should the nurse expect?

2 :
A nurse is planning care for a client who has cirrhosis of the liver. Which of the following actions should the nurse include in the plan? (Select all that apply.)

3 :
A nurse is administering an 1M injection to a client who has hepatitis C. Before placing the syringe and needle in a puncture-resistant container, which of the following actions should the nurse take?

4 :
A nurse is preparing to provide tracheostomy care for a client who has a non disposable tracheostomy tube. Which of the following equipment should the nurse plan to use? (Select all that apply.)

5 :
A nurse is caring for a client who has cirrhosis and a prothrombin time of 30 seconds. Which of the following medications should the nurse plan to administer?

6 :
A nurse is reviewing the laboratory data of a client who has acute pancreatitis. The nurse should expect to find an elevation of which of following values?

7 :
A home health nurse visits a client who has COPD and receives oxygen at 2 L/min via nasal cannula. The client reports difficulty breathing. Which of the following actions is the nurse's priority?

8 :
A nurse is teaching self-management to a client who has hepatitis B. Which of the following Instructions should the nurse include in the teaching?

9 :
A nurse is monitoring a client who reports having chills and back pain during a blood transfusion. Which of the following actions is nurse's priority?

10 :
A nurse is caring for a client who was admitted with bleeding esophageal varices and has an esophagogastric balloon tamponade with a Sengstaken-Blakemore tube to control the bleeding. Which of the following actions should the nurse take?

QLexNursing

1 : A nurse is assessing a child who is in sickle cell crisis. Which of the following findings should the nurse expect?

2 : A nurse is planning care for a client who has cirrhosis of the liver. Which of the following actions should the nurse include in the plan? (Select all that apply.)

3 : A nurse is administering an 1M injection to a client who has hepatitis C. Before placing the syringe and needle in a puncture-resistant container, which of the following actions should the nurse take?

4 : A nurse is preparing to provide tracheostomy care for a client who has a non disposable tracheostomy tube. Which of the following equipment should the nurse plan to use? (Select all that apply.)

5 : A nurse is caring for a client who has cirrhosis and a prothrombin time of 30 seconds. Which of the following medications should the nurse plan to administer?

6 : A nurse is reviewing the laboratory data of a client who has acute pancreatitis. The nurse should expect to find an elevation of which of following values?

7 : A home health nurse visits a client who has COPD and receives oxygen at 2 L/min via nasal cannula. The client reports difficulty breathing. Which of the following actions is the nurse's priority?

8 : A nurse is teaching self-management to a client who has hepatitis B. Which of the following Instructions should the nurse include in the teaching?

9 : A nurse is monitoring a client who reports having chills and back pain during a blood transfusion. Which of the following actions is nurse's priority?

10 : A nurse is caring for a client who was admitted with bleeding esophageal varices and has an esophagogastric balloon tamponade with a Sengstaken-Blakemore tube to control the bleeding. Which of the following actions should the nurse take?

1 :
A nurse is assessing a child who is in sickle cell crisis. Which of the following findings should the nurse expect?

2 :
A nurse is planning care for a client who has cirrhosis of the liver. Which of the following actions should the nurse include in the plan? (Select all that apply.)

3 :
A nurse is administering an 1M injection to a client who has hepatitis C. Before placing the syringe and needle in a puncture-resistant container, which of the following actions should the nurse take?

4 :
A nurse is preparing to provide tracheostomy care for a client who has a non disposable tracheostomy tube. Which of the following equipment should the nurse plan to use? (Select all that apply.)

5 :
A nurse is caring for a client who has cirrhosis and a prothrombin time of 30 seconds. Which of the following medications should the nurse plan to administer?

6 :
A nurse is reviewing the laboratory data of a client who has acute pancreatitis. The nurse should expect to find an elevation of which of following values?

7 :
A home health nurse visits a client who has COPD and receives oxygen at 2 L/min via nasal cannula. The client reports difficulty breathing. Which of the following actions is the nurse's priority?

8 :
A nurse is teaching self-management to a client who has hepatitis B. Which of the following Instructions should the nurse include in the teaching?

9 :
A nurse is monitoring a client who reports having chills and back pain during a blood transfusion. Which of the following actions is nurse's priority?

10 :
A nurse is caring for a client who was admitted with bleeding esophageal varices and has an esophagogastric balloon tamponade with a Sengstaken-Blakemore tube to control the bleeding. Which of the following actions should the nurse take?