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Questions 149

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Question 1 of 5

Which finding is associated with Tay Sachs disease?

Correct Answer: B

Rationale: Cherry-red spots on the macula are a classic finding in Tay-Sachs disease due to lipid accumulation in retinal ganglion cells.

Question 2 of 5

The priority nursing intervention for a client with sickle cell crisis is to

Correct Answer: D

Rationale: IV fluids are the priority in sickle cell crisis to reduce blood viscosity, promote perfusion, and prevent organ damage.

Question 3 of 5

A gravida III para II is admitted to the labor unit. Vaginal exam reveals that the client's cervix is 8 cm dilated, with complete effacement. The priority nursing diagnosis at this time is:

Correct Answer: B

Rationale: At 8 cm dilation with complete effacement, the client is in advanced labor, and the risk of precipitate delivery is high, posing a potential for injury.

Question 4 of 5

The registered nurse is making shift assignments. Which client should be assigned to the licensed practical nurse (LPN)?

Correct Answer: A

Rationale: LPNs can manage stable clients with routine care, like a diabetic with a foot ulcer requiring dressings. Heparin, tracheostomy weaning, and T-tube management involve complex assessments better suited for RNs.

Question 5 of 5

The oncology nurse is caring for a 24-year-old male client with testicular cancer. Cisplatin IV has been ordered. Which lab value would the nurse notify the health care provider about before administering this medication?

Correct Answer: C

Rationale: Cisplatin is nephrotoxic; a creatinine clearance of 23 mL/min indicates impaired renal function, requiring provider notification before administration.

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