A nurse is caring for a client during a follow up visit at a gastrointestinal clinic.

Exhibits

Which of the following interventions should the nurse implement?

Select all that apply.

Assess peripheral circulation hourly.

Assess the client's mouth every 8 hr.

Use humidification with oxygen therapy. Administer IV fluids.

Raise the knee position on the client's bed.

Use an automated blood pressure cuff on the client's arm. Prepare for platelet transfusion.

Answer and Explanation

Correct Answer : A,B,C

A. Assess peripheral circulation hourly. This is correct because clients with SCD are at risk of vaso-occlusive crisis, which can impair blood flow to the extremities and cause tissue ischemia and necrosis. The nurse should monitor for signs of poor circulation such as pallor, coolness, numbness, or pain.

B. Assess the client's mouth every 8 hr. This is correct because clients with SCD are prone to oral ulcers, infections, and dental problems due to chronic anemia and reduced oxygen delivery to the oral mucosa. The nurse should inspect the mouth for lesions, bleeding, inflammation, or infection and provide oral hygiene as needed.

C. Use humidification with oxygen therapy. Administer IV fluids. This is correct because clients with SCD need adequate hydration and oxygenation to prevent sickling of red blood cells and further complications. Humidification helps moisten the airways and prevent dehydration of the mucous membranes. IV fluids help maintain fluid and electrolyte balance and reduce blood viscosity.

D. Raise the knee position on the client's bed. This is incorrect because this can impede venous return and worsen peripheral circulation. The nurse should keep the client's extremities in a neutral position and avoid tight or restrictive clothing or devices.

E. Use an automated blood pressure cuff on the client's arm. Prepare for platelet transfusion. This is incorrect because this can cause mechanical trauma to the arm and trigger a vasoocclusive crisis. The nurse should use a manual blood pressure cuff and avoid applying pressure to the arm. Platelet transfusion is not indicated for clients with SCD unless they have thrombocytopenia or bleeding.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A rationale:

The statement, "I will take the medication in the morning," indicates lack of understanding. Metformin is usually taken with large meals, and taking it in the morning is not the best timing.

Choice B rationale:

The statement, "I will expect to gain weight," is incorrect. Weight gain is not an expected side effect of metformin. In fact, metformin is often associated with weight loss or weight maintenance, especially in individuals with diabetes, as it helps improve insulin sensitivity and glucose metabolism.

Choice C rationale:

The statement, "I will take the medication on an empty stomach," is incorrect for extended-release metformin tablets. Unlike immediate-release metformin, extended-release tablets should be taken with meals to reduce the risk of gastrointestinal side effects.

Choice D rationale:

The statement, "I will avoid crushing this medication," is correct. Metformin extended-release tablets should never be crushed or broken, as it can affect the way the medication is released into the body. Crushing or breaking the tablet can lead to a sudden release of a large amount of metformin, potentially causing an overdose.

A. Massage bony prominences on the client's left side. B. Support the client's left arm on a pillow while sitting. C. Position the bedside table on the client's left side. D. Place the client's cane on their left side while ambulating.

Correct Answer is B

Explanation

- A is incorrect because massaging bony prominences on the client's left side can increase the risk of skin breakdown and pressure ulcers. The nurse should avoid applying pressure to areas with impaired circulation or sensation.

- B is correct because supporting the client's left arm on a pillow while sitting can prevent edema, contractures, and nerve damage. The nurse should also encourage the client to perform active and passive range of motion exercises on their left arm.

- C is incorrect because positioning the bedside table on the client's left side can discourage the client from using their right side, which can lead to neglect and learned nonuse. The nurse should position the bedside table on the client's right side and encourage them to reach for items with their right hand.

- D is incorrect because placing the client's cane on their left side while ambulating can cause instability and falls. The nurse should place the cane on the client's right side and instruct them to move their left leg and cane together, followed by their right leg.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is caring for a client during a follow up visit at a gastrointestinal clinic. Exhibits Which of the following interventions should the nurse implement? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client who has a new prescription for metformin extended-release tablets. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is D

Explanation

A nurse is creating a plan of care for a client who has left-sided weakness following a stroke. Which of the following interventions should the nurse include in the plan?

Correct Answer is B

Explanation

A nurse is admitting a client to the psychiatric unit after attempting suicide. The client states, "My family does not care whether I live or die." Which of the following responses should the nurse make?

While a nurse is caring for a client who is receiving mechanical ventilation via an endotracheal tube, the high-pressure alarm on the ventilator sounds.Which of the following actions should the nurse take?

A nurse is performing an admission assessment on a client who had a recent positive pregnancy test. The first day of her last menstrual period (LMP) was May 8. According to Nägele's rule, which of the following dates should the nurse document as the client's estimated date of birth (EDB)?

A nurse is caring for a client during a follow up visit at a gastrointestinal clinic. Exhibits Which of the following interventions should the nurse implement? Select all that apply.

A nurse is teaching a client how to care for his behind-the-ear hearing aids.Which of the following statements by the client indicates an understanding of the teaching?

A nurse is caring for a client during a follow up visit at a gastrointestinal clinic.

Exhibits

Which of the following interventions should the nurse implement?

Select all that apply.