Question

A client is admitted to the emergency department in a sickle cell crisis. The nurse assesses the client and documents the following clinical findings temperature 102°F (38°C) 02 saturation of 89%, and reports of severe abdominal pain. Based on the assessment findings, which intervention is the greatest priority?

Answer 1

Correct Answers:

Apply oxygen per nasal cannula to maintain SpO2 above 93%.

Rationale :

💎The most critical concern during a sickle cell crisis is tissue hypoxia, which triggers further sickling of red blood cells, leading to vaso-occlusion and organ ischemia.

💎The client’s SpO₂ of 89% indicates inadequate oxygenation, making oxygen therapy the highest priority to prevent worsening hypoxemia and pain.

💎Once oxygenation is stabilized, pain control and hydration can follow as secondary priorities.

💎Early administration of oxygen prevents complications such as acute chest syndrome, stroke, and multi-organ damage.

💎Continuous oxygen monitoring ensures adequate perfusion and supports reversal of the sickling process.

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Answer 2

Correct Answers:

Administer prescribed opioid analgesics to manage acute pain.

Rationale :

🔷Severe pain during a sickle cell crisis results from vascular occlusion and tissue ischemia, making pain management the most immediate need.

🔷Opioid analgesics (e.g., morphine or hydromorphone) are necessary to control severe pain and reduce stress-induced oxygen demand.

🔷Effective pain control helps prevent further vasoconstriction and allows the client to relax and breathe adequately.

🔷Once pain is managed, other interventions such as IV hydration and oxygen therapy can be optimized.

🔷Nurses should also monitor for respiratory depression and assess pain regularly for adequate titration of analgesics.

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Answer 3

Correct Answers:

Vancomycin

Rationale :

🔶Vancomycin is a nephrotoxic antibiotic that can cause acute tubular necrosis, especially in clients with chronic kidney disease (CKD).

🔶Because it is excreted through the kidneys, accumulation can occur when renal function is impaired, increasing risk for toxicity.

🔶The nurse should ensure therapeutic drug monitoring (trough levels) and assess renal function (BUN, creatinine) before administration.

🔶Dose adjustments are essential to prevent further renal deterioration.

🔶Safer options or dose modifications should be discussed with the healthcare provider if renal function worsens.

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Answer 4

Correct Answers:

Potassium and phosphorus

Rationale :

🟢Clients with polycystic kidney disease (PKD) experience progressive renal impairment, which reduces the kidneys’ ability to excrete potassium and phosphorus.

🟢Elevated potassium can lead to life-threatening cardiac dysrhythmias, while high phosphorus contributes to bone demineralization and secondary hyperparathyroidism.

🟢The nurse should reinforce dietary limits on high-potassium foods (e.g., bananas, oranges, tomatoes) and phosphorus-rich foods (e.g., dairy, nuts, processed meats).

🟢A renal dietitian can help develop an individualized meal plan to maintain electrolyte balance.

🟢Monitoring serum electrolytes and ECG changes is vital for early detection of hyperkalemia or hyperphosphatemia.

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Answer 5

Correct Answers:

Malignant lymphoma

Rationale :

💠The combination of painless lymph node enlargement, night sweats, unexplained weight loss, and low-grade fever is characteristic of malignant lymphoma—either Hodgkin or non-Hodgkin type.

💠B symptoms (fever, night sweats, weight loss) indicate systemic involvement and help stage the disease severity.

💠The nurse should anticipate lymph node biopsy and further tests such as CT or PET scan for confirmation and staging.

💠Early identification allows for timely chemotherapy and radiation therapy, improving long-term prognosis.

💠Supportive nursing care includes infection prevention, monitoring for anemia, and providing emotional support due to the chronic nature of the disease.

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Answer 6

Correct Answers:

33

Rationale :

✍️1 tablespoon = 15 mL,

✍️Convert 500 mL to tablespoons:

➡️500 ÷ 15

= 33.3 tablespoons

✍️Rounded to the nearest whole number

= 33 tablespoons.

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Answer 7

Correct Answers:

Encourage the use of an electric razor for shaving.

Rationale :

🔷Clients with thrombocytopenia (low platelet count) are at increased risk for bleeding, even from minor trauma.

🔷Electric razors minimize the risk of cuts and nicks that could lead to uncontrolled bleeding compared to manual blades.

🔷Similarly, soft-bristled toothbrushes are preferred to prevent oral mucosal injury.

🔷Avoiding invasive procedures or activities that cause skin injury is a key safety principle in bleeding precautions.

🔷Nurses should also monitor for petechiae, hematuria, and bruising and ensure the client avoids aspirin or NSAIDs.

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Answer 8

Correct Answers:

The client with acute kidney Injury who has a potassium level of 6.8 mmol/L (Normal: 3.5-5.0 mmol/L).

Rationale :

🔶A serum potassium of 6.8 mmol/L indicates severe hyperkalemia, a life-threatening electrolyte imbalance.

🔶Hyperkalemia can cause fatal cardiac dysrhythmias such as ventricular fibrillation or asystole.

🔶The nurse should immediately place the client on cardiac monitoring, prepare to administer calcium gluconate, insulin with glucose, or sodium bicarbonate as prescribed.

🔶Other clients are stable compared to this one; therefore, this client takes priority.

🔶Prompt recognition and treatment are critical to prevent cardiac arrest.

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Answer 9

Correct Answers:

Ensure adequate hydration.
Complete all antibiotic therapy.
Call the provider if there are a new fever or chills.
Empty bladder completely when urinating.

Rationale :

Ensure adequate hydration

🔷 Adequate fluid intake (often ~2–3 L/day if not contraindicated) increases urinary flow, which mechanically flushes bacteria from the renal pelvis and ureters, reducing bacterial load and irritation.

🔷 Hydration helps prevent urinary stasis, a key contributor to ascending infection and recurrence.

🔷 Improved flow also dilutes inflammatory by-products that aggravate dysuria and urgency, promoting symptom relief.

🔷 In clients with heart failure or CKD, fluids should be individualized—the principle is still to avoid stasis while respecting fluid restrictions.

🔷 Teach clients to monitor urine color and frequency as simple, actionable indicators of hydration status.

Complete all antibiotic therapy

🔷 Finishing the entire prescribed antibiotic course ensures complete eradication of organisms from renal parenchyma, where tissue penetration can be more challenging than in lower UTIs.

🔷 Premature discontinuation selects for resistant strains and markedly increases the risk of relapse or recurrent pyelonephritis.

🔷 Consistent dosing maintains therapeutic serum and urinary concentrations, preventing bacterial regrowth between doses.

🔷 Reinforce what to do if a dose is missed (take it when remembered unless close to the next dose—do not double up unless directed).

🔷 Advise clients to report intolerable adverse effects promptly so therapy can be adjusted, not abandoned.

Call the provider if there are new fever or chills

🔷 New or recurrent fever/chills may indicate persistent infection, bacteremia, or urosepsis, complications that can progress rapidly without escalation of care.

🔷 Pyelonephritis can seed the bloodstream; early recognition of systemic signs enables timely cultures, labs, and antibiotic adjustment.

🔷 Other danger signs to report include worsening flank pain, persistent vomiting, hypotension, or confusion, which suggest clinical deterioration.

🔷 Prompt contact can prevent renal scarring and hemodynamic instability, especially in older adults or those with immunosuppression.

🔷 Clarify who to call and when (24/7 contact, urgent care vs. ED) to remove barriers to rapid follow-up.

Empty bladder completely when urinating

🔷 Incomplete emptying leads to urinary stasis, which nurtures bacterial persistence and promotes recurrent infection.

🔷 Teach double-voiding (void, wait a minute, try again) and unhurried toileting to enhance bladder emptying efficiency.

🔷 Encourage voiding every 2–3 hours while awake and after intercourse to promptly expel bacteria introduced into the lower tract.

🔷 Proper positioning (feet supported, leaning slightly forward) and pelvic floor relaxation can improve flow and completeness.

🔷 Address factors that impair emptying—e.g., constipation management, review of anticholinergic medications—to lower recurrence risk.

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Answer 10

Correct Answers:

Oliguria

Rationale :

💎Oliguria is defined as a decrease in urine output below 400 mL per 24 hours in adults, indicating impaired renal perfusion or renal dysfunction.

💎The client’s urine output of 350 mL in 24 hours clearly meets this definition and suggests the kidneys are not adequately filtering or excreting waste.

💎Common causes include dehydration, acute kidney injury (AKI), hypovolemia, or urinary obstruction.

💎The nurse should promptly assess fluid balance, monitor vital signs, and report findings to the provider to prevent renal failure progression.

💎Timely intervention—such as fluid resuscitation, medication review, or renal function testing (BUN, creatinine)—is critical for restoring kidney perfusion and output.

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QLexNursing

2 :
A client with sickle cell anemia is admitted to the hospital with reports of severe leg pain and fatigue during a sickle cell crisis. What is the nurse's highest priority action

3 :
The nurse is reviewing the medication list of a client with chronic kidney disease. Which medication should the nurse identify as requiring caution due to its potential to worsen kidney function?

4 :
The nurse is caring for a client with polycystic kidney disease. The nurse recognizes the need for a diet modification consistent with impaired renal function. Which dietary nutrients should be reduced to prevent severe complications?

5 :
A client presents with painless enlargement of cervical lymph nodes, night sweats, and unexplained weight loss over the past three months. The client also reports persistent fatigue and intermittent low-grade fever. Based on these findings, which diagnosis should the nurse suspect?

6 :
A client is prescribed a liquid medication that is supplied in a 500 ml bottle. How many tablespoons are in this bottle? Round the answer to the nearest whole number

7 :
The nurse is caring for a client with thrombocytopenia.

Answer Options

8 :
The nurse receives a shift report about four clients. Which client should the nurse assess first? Laboratory Test, Serum Potassium, Normal Findings (Conventional Units) 3.5-5.0 mmol/L.

10 :
The nurse is caring for a client who has had a urine output of 350L in the past 24 hours. What term should the nurse use when documenting this finding in the electron with record?

QLexNursing

2 : A client with sickle cell anemia is admitted to the hospital with reports of severe leg pain and fatigue during a sickle cell crisis. What is the nurse's highest priority action

3 : The nurse is reviewing the medication list of a client with chronic kidney disease. Which medication should the nurse identify as requiring caution due to its potential to worsen kidney function?

4 : The nurse is caring for a client with polycystic kidney disease. The nurse recognizes the need for a diet modification consistent with impaired renal function. Which dietary nutrients should be reduced to prevent severe complications?

5 : A client presents with painless enlargement of cervical lymph nodes, night sweats, and unexplained weight loss over the past three months. The client also reports persistent fatigue and intermittent low-grade fever. Based on these findings, which diagnosis should the nurse suspect?

6 : A client is prescribed a liquid medication that is supplied in a 500 ml bottle. How many tablespoons are in this bottle? Round the answer to the nearest whole number

7 : The nurse is caring for a client with thrombocytopenia.

Answer Options

8 : The nurse receives a shift report about four clients. Which client should the nurse assess first? Laboratory Test, Serum Potassium, Normal Findings (Conventional Units) 3.5-5.0 mmol/L.

10 : The nurse is caring for a client who has had a urine output of 350L in the past 24 hours. What term should the nurse use when documenting this finding in the electron with record?

2 :
A client with sickle cell anemia is admitted to the hospital with reports of severe leg pain and fatigue during a sickle cell crisis. What is the nurse's highest priority action

3 :
The nurse is reviewing the medication list of a client with chronic kidney disease. Which medication should the nurse identify as requiring caution due to its potential to worsen kidney function?

4 :
The nurse is caring for a client with polycystic kidney disease. The nurse recognizes the need for a diet modification consistent with impaired renal function. Which dietary nutrients should be reduced to prevent severe complications?

5 :
A client presents with painless enlargement of cervical lymph nodes, night sweats, and unexplained weight loss over the past three months. The client also reports persistent fatigue and intermittent low-grade fever. Based on these findings, which diagnosis should the nurse suspect?

6 :
A client is prescribed a liquid medication that is supplied in a 500 ml bottle. How many tablespoons are in this bottle? Round the answer to the nearest whole number

7 :
The nurse is caring for a client with thrombocytopenia.

8 :
The nurse receives a shift report about four clients. Which client should the nurse assess first? Laboratory Test, Serum Potassium, Normal Findings (Conventional Units) 3.5-5.0 mmol/L.

10 :
The nurse is caring for a client who has had a urine output of 350L in the past 24 hours. What term should the nurse use when documenting this finding in the electron with record?