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Question 1 of 5

A client with sickle cell disease is admitted in active labor. Which nursing intervention would be most helpful in preventing a sickling crisis?

Correct Answer: D

Rationale: IV fluids at 200 mL/hr prevent dehydration, a trigger for sickling crises, by maintaining hydration and blood flow. BP monitoring (
A), pain medication (
B), and ABGs (
C) are supportive but less directly preventive.

Question 2 of 5

In planning daily care for a client with multiple sclerosis, the nurse would take into consideration that multiple sclerosis:

Correct Answer: B

Rationale: Multiple sclerosis eventually becomes debilitating, but it is characterized by remission of symptoms. Remissions and exacerbations are unpredictable with multiple sclerosis. The client experiences progressive dysfunction after each exacerbation episode. Multiple sclerosis is usually slowly progressive. Multiple sclerosis is an autoimmune disease. Antimicrobial therapy has no effect on its course.

Question 3 of 5

A client with angina is experiencing migraine headaches. The physician has prescribed Sumatriptan succinate (Imitrex). Which nursing action is most appropriate?

Correct Answer: A

Rationale: Sumatriptan, a triptan, is contraindicated in angina due to vasoconstrictive effects, risking coronary ischemia. Questioning the order (
A) is priority. Samples (
B), teaching (
C), and financial aid (
D) are inappropriate without resolving the contraindication.

Question 4 of 5

A 40-year-old client is admitted to the hospital for tests to diagnose cancer. Since his admission, he has become dependent and demanding to the nursing staff. The nurse identifies this behavior as which defense mechanism?

Correct Answer: C

Rationale: Regression involves reverting to an earlier developmental stage, such as dependency, in response to stress like a cancer diagnosis.

Question 5 of 5

The nurse explains perineal hygiene self-care postpartum to the client. She should be instructed to:

Correct Answer: C

Rationale: (
Tom) Perineal hygiene is a clean procedure and does not require the client to wear gloves. A care provider should wear gloves to adhere to universal precautions. The pad should be applied from front to back to prevent contamination of the birth canal or urinary tract from rectal bacteria. Wiping from front to back and discarding the wipe prevents contamination of the urinary tract and birth canal from rectal bacteria. The inner surface of the pad should not be touched to maintain asepsis.

Similar Questions

Following a gastric resection, a 70-year-old client is admitted to the postanesthesia care unit. He was extubated prior to leaving the suite. On arrival at the postanesthesia care unit, the nurse should:
A female client presents to the obstetric-gynecology clinic for a pregnancy test, the result which turns out to be positive. Her last menstrual period began December 10, 1993. Using Nägele's rule, the nurse estimates her date of delivery to be:
A client with a history of heart failure is admitted with complaints of dyspnea. The nurse should give priority to:
The nurse is preparing to check a client for Trousseau's sign. Which equipment should the nurse obtain?
A 9-month-old infant was diagnosed with nonorganic failure to thrive. During her hospitalization, primary nurses were assigned to initiate all infant feedings. The infant's parents question why they cannot feed their own child. Which of the following responses would be most appropriate by the nurse?

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