A nurse is caring for a client during a follow up visit at a gastrointestinal clinic.
Nurses' Notes
0600:
Client admitted to the ED with fatigue, shortness of breath, and weakness for the last 2 days. Client states that they have a history of sickle cell disease (SCD). Client is alert and orientated to person, place, and time. Restless. Client rates generalized pain as a 9 on a scale of 0 to 10. Vital signs taken and blood drawn for laboratory tests. Oxygen 2 L via nasal cannula applied. Awaiting prescription for pain management.
0615:
Client still rates pain as a 9 on a scale of 0 to 10. Hydromorphone 4 mg IV administered.
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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Fidelity refers to the principle of being loyal, faithful, and keeping promises. It does not specifically relate to providing accurate information about treatment effects. In this scenario, the nurse is discussing the potential adverse effects of a treatment, which falls under the domain of providing accurate and truthful information to the client.
Choice B rationale:
Beneficence is the ethical principle of doing good and promoting the well-being of the patient. While educating the client about potential adverse effects is a form of beneficence, the specific principle demonstrated in this scenario is veracity, which is the duty to tell the truth. The nurse is being truthful about the potential side effect (lightheadedness) while clarifying that it should not affect memory.
Choice C rationale:
Veracity is the ethical principle of truth-telling. In this scenario, the nurse is demonstrating veracity by providing honest and accurate information to the client about the potential adverse effects of transcranial magnetic stimulation. By being truthful, the nurse upholds the ethical principle of veracity.
Choice D rationale:
Autonomy refers to the principle of respecting the patient's right to make decisions about their own healthcare. While respecting autonomy is important, the nurse's action in this scenario specifically pertains to providing accurate information (veracity) rather than solely focusing on the client's decision-making autonomy.
Correct Answer is A
Explanation
- A. Pink, frothy sputum is a characteristic finding of pulmonary edema, which is caused by fluid accumulation in the alveoli and interstitial spaces of the lungs. This impairs gas exchange and leads to hypoxia and respiratory distress.
- B. Bradycardia is not expected in pulmonary edema. The client is more likely to have tachycardia due to increased sympathetic stimulation and decreased cardiac output.
- C. Flushed, dry skin is not expected in pulmonary edema. The client is more likely to have pale, cool, and clammy skin due to peripheral vasoconstriction and decreased perfusion.
- D. Wheezing is not a specific finding of pulmonary edema. It may indicate bronchospasm or asthma, which are different conditions that affect the airways rather than the alveoli.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.