A nurse is caring for a client who has sickle cell disease.

Client reports fatigue, muscle weakness, joint pain, and dyspnea. Sclera is jaundiced. A 2.5 cm (1 in) by 2.5 cm (1 in) open ulcer is noted on the inner left ankle.

Exhibits

For each client finding, click to specify if the finding is consistent with sickle cell disease, iron deficiency anemia, or leukemia. Each finding may support more than one disease process.

Joint pain

Heart Rate at 1000

Respiratory status

Jaundice

Ankle ulcer

Answer and Explanation

The Correct Answer is {"A":{"answers":"A,C"},"B":{"answers":"A,B,C"},"C":{"answers":"A,B,C"},"D":{"answers":"A,C"},"E":{"answers":"A"}}

Joint Pain

Sickle Cell Disease: Joint pain is a common symptom of sickle cell disease due to vaso-occlusive crises, where sickle- shaped red blood cells block blood flow to the joints, causing pain and inflammation. These episodes can be severe and recurrent, leading to chronic pain and joint damage over time.

Leukemia: Joint pain can also be a symptom of leukemia, particularly in children. This occurs because leukemia cells can infiltrate the bone marrow, causing bone and joint pain. The pain is often due to the expansion of the marrow cavity by the leukemic cells.

Heart Rate at 1000

Sickle Cell Disease: An increased heart rate (tachycardia) can occur in sickle cell disease due to anemia. The body compensates for the reduced oxygen-carrying capacity of the blood by increasing the heart rate.

Iron Deficiency Anemia: Tachycardia is also a common symptom of iron deficiency anemia. The heart works harder to pump more blood to deliver adequate oxygen to tissues, resulting in an increased heart rate.

Leukemia: In leukemia, anemia can develop due to the replacement of normal bone marrow cells with leukemic cells, leading to a reduced number of red blood cells and subsequent tachycardia as the body attempts to compensate.

Respiratory Status

Sickle Cell Disease: Dyspnea (difficulty breathing) and labored breathing can occur in sickle cell disease due to anemia and acute chest syndrome, a severe complication where sickle cells block blood flow in the lungs.

Iron Deficiency Anemia: Respiratory symptoms such as shortness of breath and labored breathing are common in iron deficiency anemia due to the reduced oxygen-carrying capacity of the blood.

Leukemia: Leukemia can cause respiratory symptoms due to anemia and the infiltration of leukemic cells into the lungs, leading to reduced oxygenation and labored breathing.

Jaundice

Sickle Cell Disease: Jaundice is a common symptom of sickle cell disease due to the increased breakdown of red blood cells (hemolysis), leading to elevated bilirubin levels.

Leukemia: Jaundice can also occur in leukemia if the liver is infiltrated by leukemic cells or if there is significant hemolysis.

Ankle Ulcer

Sickle Cell Disease: Ankle ulcers are a common complication of sickle cell disease. They result from poor blood flow and oxygen delivery to the skin, leading to chronic, non-healing ulcers.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A reason: A client who had a stroke and is to be admitted

Assigning a client who had a stroke and is to be admitted might not be the best choice for an RN floated from the maternal-newborn unit. Stroke patients often require specialized neurological assessments and interventions that the RN might not be familiar with. Additionally, the initial admission process can be complex and time-consuming, requiring familiarity with the specific protocols and procedures of the medical-surgical unit.

Choice B reason: A client who is one-day postoperative following a total abdominal hysterectomy

This is the most appropriate assignment for the RN floated from the maternal-newborn unit. The RN is likely to be familiar with postoperative care, especially related to abdominal surgeries, given their experience in the maternal-newborn unit. Postoperative care involves monitoring vital signs, managing pain, and ensuring proper wound care, all of which are within the RN’s skill set. This familiarity can help ensure the client receives competent and safe care.

Choice C reason: A client who has acute pancreatitis

Acute pancreatitis can be a complex condition requiring specialized knowledge of gastrointestinal issues and potential complications such as fluid and electrolyte imbalances, respiratory issues, and severe pain management. The RN from the maternal-newborn unit may not have the specific expertise needed to manage these complexities effectively.

Choice D reason: A client who has terminal end-stage renal disease

Caring for a client with terminal end-stage renal disease involves managing complex chronic conditions, including fluid balance, electrolyte management, and possibly dialysis. This requires specialized knowledge and skills that the RN from the maternal-newborn unit might not possess. Additionally, end-of-life care requires a specific set of competencies and experience that might not be within the RN’s usual scope of practice.

A. Using a kitchen spoon to administer the medication. B. Written information about the medication. C. The reason why the child is taking the medication. D. The adverse effects of the medication. E. Stopping the medication when the child feels better.

Correct Answer is ["B","C","D"]

Explanation

Choice A reason: Using a kitchen spoon to administer the medication is not recommended. Kitchen spoons can vary in size and may not provide an accurate dose. It is important to use a proper measuring device, such as an oral syringe or a medication cup, to ensure the correct dosage.

Choice B reason: Written information about the medication is crucial for the parents or caregivers. This information should include the name of the medication, the dosage, the frequency of administration, and any special instructions. Providing written information helps ensure that the medication is administered correctly and consistently.

Choice C reason: The reason why the child is taking the medication should be clearly explained to the parents or caregivers. Understanding the purpose of the medication helps ensure compliance and allows them to monitor the child’s response to the treatment.

Choice D reason: The adverse effects of the medication should be discussed with the parents or caregivers. Knowing the potential side effects allows them to recognize and respond to any adverse reactions promptly. This information is essential for the safe administration of the medication.

Choice E reason: Stopping the medication when the child feels better is incorrect. Antibiotics should be taken for the full prescribed course, even if the child starts to feel better before the medication is finished. Stopping the medication early can lead to incomplete treatment of the infection and contribute to antibiotic resistance.

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Heart Rate at 1000

Respiratory Status

Jaundice

Ankle Ulcer

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An RN from the maternal-newborn unit is being floated to a medical-surgical unit. Which of the following clients should the charge nurse on the medical-surgical unit plan to assign to the RN?

Correct Answer is B

Explanation

A nurse is preparing to discharge a child who has a new prescription for an oral antibiotic. Which of the following information should the nurse include in the discharge instructions? (Select all that apply)

Correct Answer is ["B","C","D"]

Explanation

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A nurse is preparing to administer lansoprazole 30 mg PO daily to a client. The amount available is lansoprazole 10 mg per tablet. How many tablets should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

A nurse is caring for a client who has a prescription for potassium chloride (KCL) 20 mEq PO daily. The nurse reviews the client’s most recent laboratory results and finds the client’s potassium level is 5.2 mEq/L. Which of the following actions should the nurse take?

A nurse is caring for several clients. For which of the following situations should the nurse complete an incident report?