A client is experiencing sickle cell crisis precipitated by a right lower lobe pneumonia. The vital signs are: HR-110/min: RR-28; B/P-96/54: T-100.8 PO: Pulse Oximetry-96%. What is the best nursing action?

Maintain IV fluid infusion and assess adequacy of hydration

Provide continuous sedation for pain relief

Insert an indwelling (Foley) catheter and monitor hourly urinary output

Prepare for endotracheal intubation and ventilatory support

Answer and Explanation

The Correct Answer is A

A) Maintain IV fluid infusion and assess adequacy of hydration: This is the best nursing action as adequate hydration is crucial in managing sickle cell crisis. It helps to reduce blood viscosity and prevent further sickling of red blood cells, which is especially important in the context of pneumonia, as dehydration can exacerbate the crisis.

B) Provide continuous sedation for pain relief: While managing pain is essential, continuous sedation is not the most appropriate first step in this situation. Pain management should be addressed, but hydration and treating the underlying causes (like pneumonia) take priority.

C) Insert an indwelling (Foley) catheter and monitor hourly urinary output: While monitoring urinary output can be important, it is not the most immediate action in this case. Focus should be on hydration and addressing the sickle cell crisis rather than on urinary output at this time.

D) Prepare for endotracheal intubation and ventilatory support: Although respiratory distress is a concern with pneumonia, the current pulse oximetry reading of 96% indicates adequate oxygenation at this time. Preparing for intubation should not be the first action unless the patient shows signs of respiratory failure or severe distress.

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Correct Answer is D

Explanation

A. Meat and eggs mostly contain unsaturated fats: This statement is incorrect. Meat and eggs are primarily sources of saturated fats, which should be limited in a diet aimed at reducing coronary artery disease risk.
B. Coconut oil has a rich flavor and is a good cooking oil: This is misleading. While coconut oil is popular, it is high in saturated fats, and many health guidelines recommend limiting its use, especially for those with coronary artery disease.

C. "Olive oil is high in saturated fats so I should avoid it": This statement is also incorrect. Olive oil is primarily composed of monounsaturated fats, which are considered heart-healthy and are recommended in moderation for individuals with coronary artery disease.

D. "Canola oil is a monounsaturated fat and is recommended": This statement is accurate. Canola oil contains a high proportion of monounsaturated fats and is often recommended as a healthier option for cooking and salad dressings for those looking to limit saturated fat intake.

A. Bone marrow aspiration study B. Vitamin B2 level C. Stool for occult blood D. Schelling's test

Correct Answer is C

Explanation

A. Bone marrow aspiration study: While this test can provide information about the bone marrow's ability to produce red blood cells, it is not typically the first diagnostic test used to detect the cause of chronic iron deficiency anemia.

B. Vitamin B2 level: This test measures riboflavin levels, which are not related to iron deficiency anemia. Vitamin B12 or folate levels are more relevant in differentiating types of anemia.

C. Stool for occult blood: This test is commonly used to detect hidden blood in the stool, which can indicate gastrointestinal bleeding—a frequent cause of chronic iron deficiency anemia. Identifying blood loss in the GI tract is crucial for diagnosing the underlying issue.

D. Schelling's test: This test is used to determine the absorption of vitamin B12 and is not
applicable to iron deficiency anemia.

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A client is experiencing sickle cell crisis precipitated by a right lower lobe pneumonia. The vital signs are: HR-110/min: RR-28; B/P-96/54: T-100.8 PO: Pulse Oximetry-96%. What is the best nursing action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is conducting dietary teaching for a client diagnosed with coronary artery disease. Which statement made by the client indicates an understanding of fat sources and the need to limit saturated fats?

Correct Answer is D

Explanation

The nurse recognizes that which diagnostic test is used to detect the most common cause of chronic iron deficiency anemia?

Correct Answer is C

Explanation

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