A nurse is caring for a client who has sickle cell anemia and is experiencing a vaso-occlusive crisis. The client belongs to the Jehovah's Witness faith and refuses blood transfusions. What is the best action for the nurse to take?

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Question 1 of 5

A nurse is caring for a client who has sickle cell anemia and is experiencing a vaso-occlusive crisis. The client belongs to the Jehovah's Witness faith and refuses blood transfusions. What is the best action for the nurse to take?

Correct Answer: A

Rationale: The nurse should respect the client's right to autonomy and self-determination, and honor their religious beliefs and preferences regarding blood transfusions. The nurse should provide supportive care, such as hydration, oxygenation, pain management, and infection prevention, to help the client cope with the vaso-occlusive crisis.

Question 2 of 5

The nurse is using Gordon's 11 categories for data collection in performing a health assessment. Which of the following represents assessment of cognition?

Correct Answer: A

Rationale: Assessing cognition involves evaluating mental processes like education level (A), per Gordon’s cognitive-perceptual pattern. B assesses health perception-health management, C evaluates nutritional-metabolic patterns, and D relates to coping-stress tolerance, making A the correct cognitive assessment.

Question 3 of 5

Which of these strategies should be a priority when the nurse is planning care for a patient with hypertension?

Correct Answer: C

Rationale: Evidence-based guidelines (C) ensure effective, standardized care for hypertension, prioritizing interventions. A (cost) and D (exercise teaching) are secondary, while B (diet) is part of guidelines but not the first action without evidence basis, making C the planning priority.

Question 4 of 5

An RN is making assignments on a medical-surgical unit. Which patient could the RN assign to a float RN from the maternity unit?

Correct Answer: A

Rationale: A stable COPD/pneumonia patient (A) is suitable for a float RN from maternity, requiring basic care. B (unstable HR), C (low BP post-surgery), and D (neutropenia) need advanced skills, making A the safest assignment.

Question 5 of 5

The nurse is planning care for an 82-year-old obese female patient with Alzheimer's dementia. The patient wanders,is unsteady on her feet and is visually impaired. What should the nurse give priority to when developing the plan of care?

Correct Answer: C

Rationale: Safety (C) is the priority due to wandering, unsteadiness, and visual impairment, risking falls in Alzheimer’s. A, B, and D are monitored but secondary, making C the immediate concern.

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