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Questions 149

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Question 1 of 5

A client is admitted with sickle cell crises and sequestration. Upon assessing the client, the nurse would expect to find:

Correct Answer: A

Rationale: Sickle cell crisis with sequestration can lead to hypovolemia due to blood pooling in organs, resulting in decreased blood pressure.

Question 2 of 5

A client has been instructed in the application and use of anti-embolic compression stockings. Which of the following statements by the client indicates a need for more teaching? Select all that apply.

Correct Answer: A,B,D

Rationale: Rolling the top down (
A) can impede circulation, removing stockings every 1-2 days (
B) is too infrequent (should be every 8 hours), and baby powder (
D) can cause skin irritation. Turning the stocking inside out (
C) and preventing clots (E) are correct.

Question 3 of 5

A client requires insertion of a nasogastric tube. When preparing the client for the procedure, the nurse should place the client in which of the following positions?

Correct Answer: A

Rationale: High Fowler's position with the head tilted forward (
A) facilitates nasogastric tube insertion by aligning the esophagus and reducing the risk of aspiration. Tilting the head backward (B,
D) or using a neutral position in semi-Fowler's (
C) is less effective for this procedure.

Question 4 of 5

The physician has ordered 50 mEq of potassium chloride for a client with a potassium level of 2.5 mEq. The nurse should administer the medication:

Correct Answer: C

Rationale: Potassium chloride should be administered slowly (e.g., over 5 hours for 50 mEq) to prevent cardiac complications, as rapid infusion can cause hyperkalemia.

Question 5 of 5

A mother tells the nurse that her daughter has become quite a collector, filling her room with Beanie babies, dolls, and stuffed animals. The nurse recognizes that the child is developing:

Correct Answer: C

Rationale: Collecting items reflects concrete operational thinking, where children (ages 7-11) organize and categorize objects systematically, per Piaget's stages.

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