NCLEX- RN Practice Exam 7

EXPLANATION

✔Correct answer:

Mr. Thompson was left alone despite being at risk for falls. In this scenario, several critical factors indicate potential negligence. One of the most significant is that Mr. Thompson, a heart failure patient who received an additional dose of bumetanide, a potent diuretic, was left alone despite being at high risk for falls. Diuretics can cause rapid fluid loss, leading to dehydration, hypotension, and dizziness, which significantly increases the risk of falls. Nurse Ellis had a responsibility to ensure Mr. Thompson's safety by closely monitoring him, especially after an additional dose of medication that could exacerbate these risks. The failure to provide such supervision supports the claim of malpractice due to negligence.

Bumetanide is a loop diuretic that works by inhibiting the reabsorption of sodium and chloride in the kidneys, leading to increased urine production. This can result in rapid fluid and electrolyte imbalances, particularly hypokalemia and hypovolemia, which can cause dizziness, hypotension, and increased fall risk, especially in heart failure patients who may already have compromised circulatory stability.

Think of a heart failure patient like a delicate plant that needs careful watering (fluid balance). Adding extra water (diuretic) quickly can make the soil too dry (dehydration), causing the plant to wilt (dizziness) and easily tip over (fall risk). Leaving the plant without support after this extra watering increases the chance it will fall over.

Nurses must closely monitor patients receiving potent diuretics like bumetanide, especially after an additional dose. This includes:

• Regularly assessing vital signs to monitor for signs of hypotension and dehydration.
• Ensuring the patient is not left alone and has assistance when moving to prevent falls.
• Monitoring fluid and electrolyte levels to prevent imbalances.
• Educating the patient on the importance of calling for assistance when feeling dizzy or weak.
• Implementing fall precautions, such as bed alarms and close observation.

✘Incorrect answer options:

Nurse Ellis did not monitor Mr. Thompson's vital signs after the additional dose. While this is concerning and part of the overall negligence, the primary issue here is that Mr. Thompson was left alone. Monitoring vital signs alone is not sufficient if the patient is left in a vulnerable state without supervision.

The medication dosage prescribed by the physician was incorrect. There is no indication that the physician's prescription was incorrect. The issue at hand is the supervision and monitoring of Mr. Thompson post-administration, not the prescription itself.

The hospital failed to provide enough nursing staff for proper patient monitoring. While staffing levels are crucial, the immediate responsibility for patient safety falls on the nurse caring for Mr. Thompson. The scenario specifically highlights Nurse Ellis's actions, indicating that the decision to leave Mr. Thompson alone was the critical factor.

EXPLANATION

✔Correct answer:

A client who needs frequent ambulation. Ambulation of clients is a task that falls well within the scope of practice for nursing assistants (NAs). This task does not require advanced nursing skills or clinical judgment and is appropriate for delegation to an NA. Frequent ambulation helps to maintain and improve a client's mobility, prevent complications such as deep vein thrombosis, and improve overall well-being. Nursing assistants are trained to assist clients with walking, ensuring their safety, and providing support as needed.

Think of delegating tasks like packing a suitcase for a trip. The nursing assistant can handle packing the basic items like clothes (ambulation), while more complex and sensitive items like medication (vital signs monitoring, wound care) should be managed by someone with more expertise, like the nurse.

When delegating tasks to a nursing assistant, it's essential to ensure they are adequately trained for the specific task and to provide clear instructions and supervision.

• Ensure the NA understands the ambulation schedule and any specific needs of the client.
• Provide guidance on how to assist clients safely and effectively during ambulation.
• Monitor the client’s response to ambulation and address any issues that arise promptly.
• Document the client’s ambulation activities and any observations made by the NA.

✘Incorrect answer options:

A client who needs wound irrigation. Wound irrigation is a procedure that requires sterile technique and clinical judgment to prevent infection and ensure proper wound healing. This task is beyond the scope of practice for a nursing assistant and should be performed by a licensed nurse.

A client receiving continuous tube feedings. Continuous tube feedings require careful monitoring to ensure the correct rate, prevent complications such as aspiration, and manage any tube-related issues. This task requires nursing knowledge and assessment skills, making it inappropriate for delegation to an NA.

A client requiring frequent vital signs monitoring after a cardiac catheterization. Clients who have undergone cardiac catheterization are at risk for complications such as bleeding or changes in cardiac status. Frequent vital signs monitoring is critical for detecting these complications early and requires the clinical assessment skills of a licensed nurse. Therefore, it should not be delegated to a nursing assistant.

EXPLANATION

✔Correct answer:

Nursing staff work under the leadership of a nurse to care for a group of clients. The team nursing model involves a group of nursing staff led by a registered nurse (RN) who coordinates care for a group of clients. This model emphasizes collaboration and delegation, where the RN acts as the team leader and is responsible for planning, assigning, and evaluating the care provided by other team members, which may include licensed practical nurses (LPNs), licensed vocational nurses (LVNs), and nursing assistants (NAs). The team works together to deliver comprehensive care to the patients, utilizing each member's skills and expertise efficiently.

Imagine a symphony orchestra where the conductor (RN) directs various musicians (LPNs, NAs) playing different instruments. The conductor ensures that each musician knows their part and coordinates their efforts to create harmonious music (quality patient care).

In the team nursing model, the nurse leader must ensure effective communication, proper delegation of tasks, and continuous monitoring of the care provided by the team members.

• Communicate clearly and regularly with team members to coordinate patient care activities.
• Assign tasks based on the skills and competencies of each team member.
• Provide support and guidance to team members as needed.
• Evaluate patient outcomes and team performance to identify areas for improvement.
• Foster a collaborative environment to enhance team dynamics and patient care quality.

✘Incorrect answer options:

A task-based method is used to deliver client care. This description fits the functional nursing model, not the team nursing model. In functional nursing, care is divided into tasks that are assigned to different staff members based on their roles and skills, rather than coordinating care as a team under a leader.

Managed care principles and tools guide client care. This description pertains to the managed care model, which focuses on cost-effective care delivery by utilizing specific principles and tools to manage health care services, rather than a collaborative team approach.

One registered nurse assumes responsibility for the nursing care of a group of clients. This statement describes the primary nursing model, where one RN is accountable for the comprehensive care of a specific group of patients throughout their stay, providing consistency and continuity of care.

EXPLANATION

✔Correct answer:

"We'll keep all hot drinks and liquids away from the edge of the counters." Keeping hot drinks and liquids away from the edge of the counters is the most practical and immediate measure that parents can take to prevent accidents like burns from occurring again. This action directly addresses the cause of the initial injury – the child pulling a hot cup of coffee from the counter. By ensuring that hot items are placed well away from the edge, the risk of a child reaching up and pulling them down is significantly minimized.

Think of the edge of the counter like a cliff. If you put valuable items (hot drinks) right at the edge, there's a high risk they'll fall off (cause burns). By moving them back from the edge, you reduce the risk of them falling and causing harm.

Nurses can educate parents on creating a safe home environment by taking preventive measures to avoid accidents, such as burns, by teaching them safe practices.

• Keep hot liquids and foods away from the edges of counters and tables.
• Use the back burners on the stove and turn pot handles inward.
• Supervise children closely in the kitchen and other areas where hot items are present.
• Explain the importance of not carrying hot liquids while holding a child.
• Consider placing child safety locks on cabinets containing hot appliances.

✘Incorrect answer options:

"We'll only use travel mugs with lids when in the kitchen." While using travel mugs with lids can reduce the risk of spills, it does not address the fundamental issue of keeping hot liquids out of a child's reach. Children can still grab and potentially spill these containers if they are left within their reach.

"We'll make sure our child doesn't go into the kitchen when we're cooking." This strategy can be difficult to enforce consistently, especially in homes with an open floor plan or where the kitchen is a central activity area. Additionally, it does not eliminate the risk of a child encountering hot liquids when not being actively supervised.

"We'll install a safety gate at the entrance to the kitchen." Installing a safety gate can help keep a child out of the kitchen, but it is not a foolproof solution. Children might find ways to bypass the gate, and it does not prevent burns from hot liquids left in other accessible areas of the house.

EXPLANATION

✔Correct answers:

Through the skin. Anthrax can be transmitted through the skin, particularly when handling contaminated animal products. This form is known as cutaneous anthrax, and it occurs when Bacillus anthracis spores enter a cut or abrasion on the skin.

Via inhalation. Inhalation anthrax occurs when a person breathes in anthrax spores. This is the most severe form of anthrax and can result from inhaling spores from contaminated animal products or deliberately aerosolized spores.

Through the gastrointestinal tract. Gastrointestinal anthrax occurs when a person consumes undercooked or raw meat from infected animals. The spores can enter the gastrointestinal tract, causing infection.

Think of anthrax spores as tiny seeds. These seeds can land on your skin and sprout if there's a cut (cutaneous anthrax), be breathed in through the air (inhalation anthrax), or be eaten with contaminated food (gastrointestinal anthrax). Each route is like a different path the seeds can take to cause harm.

✘Incorrect answer options:

By kissing. Anthrax is not transmitted through person-to-person contact, including kissing. The bacteria do not spread through saliva or mucous membranes in casual contact.

Direct contact with an infected person. Similar to kissing, direct contact with an infected person is not a route of transmission for anthrax. The spores must enter through a break in the skin, be inhaled, or ingested to cause infection.

Sexual contact with an infected person. Sexual contact is not a recognized mode of transmission for anthrax. The spores do not spread through bodily fluids exchanged during sexual activity.

EXPLANATION

✔ Correct answer:

Decreased cardiac output related to bradycardia. In the context of hypothyroidism, the most critical concern is often the impact on cardiovascular function. Hypothyroidism leads to a decreased metabolic rate, which can result in bradycardia (slow heart rate) and decreased cardiac output. A pulse of 52 is indicative of bradycardia, which can significantly impact the body's ability to perfuse vital organs effectively. Prioritizing the nursing diagnosis of decreased cardiac output is crucial because it directly affects the patient’s overall hemodynamic stability and can lead to serious complications if not managed appropriately.

Hypothyroidism causes a decrease in thyroid hormone levels, leading to a reduced metabolic rate. This impacts the cardiovascular system by slowing the heart rate and reducing the force of cardiac contractions, which can result in decreased cardiac output. This decrease can impair tissue perfusion and oxygenation, leading to fatigue, dizziness, and potential organ dysfunction.

Think of the heart as a pump that circulates water (blood) through a garden (body). If the pump slows down, the water flow decreases, leading to insufficient watering (perfusion) of the plants (organs), which can cause them to wilt (dysfunction).

Nurse Emily should closely monitor Ms. Rodriguez's heart rate, blood pressure, and other signs of cardiac function. It is important to manage symptoms and prevent complications related to decreased cardiac output.

• Monitor vital signs regularly, especially heart rate and blood pressure.
• Assess for signs of poor perfusion, such as dizziness, fatigue, and decreased urine output.
• Administer thyroid hormone replacement therapy as prescribed to normalize thyroid levels and improve metabolic rate.
• Educate the patient about the importance of medication adherence and regular follow-up to monitor thyroid function.
• Encourage a balanced diet and appropriate exercise to support overall cardiovascular health.

✘ Incorrect answer options:

Impaired physical mobility related to decreased endurance. While decreased endurance and physical mobility are concerns in hypothyroidism, they are not immediately life-threatening and do not take precedence over issues related to cardiac output.

Hypothermia related to decreased metabolic rate. Hypothermia is a concern due to the reduced metabolic rate in hypothyroidism, but it is typically less urgent than decreased cardiac output, which can lead to more severe complications if not addressed promptly.

Disturbed thought processes related to interstitial edema. Cognitive impairment can occur in hypothyroidism, often due to interstitial edema. However, it is not as critical as ensuring adequate cardiac output, which is vital for overall health and function.

EXPLANATION

✔ Correct answer:

Check the patient's calcium level. Tingling around the mouth and in the fingers and toes after a total thyroidectomy is a classic sign of hypocalcemia, which can occur if the parathyroid glands are inadvertently damaged or removed during surgery. The parathyroid glands regulate calcium levels in the body, and their impairment can lead to low calcium levels, resulting in symptoms such as tingling, muscle cramps, and even tetany. Therefore, the most critical action for Nurse Laura is to check Mr. Jenkins' calcium level to confirm hypocalcemia and initiate appropriate treatment.

The parathyroid glands, located near or within the thyroid gland, produce parathyroid hormone (PTH), which is crucial for calcium homeostasis. Total thyroidectomy can sometimes affect these glands, leading to decreased PTH production and subsequent hypocalcemia.

Think of the parathyroid glands as the thermostat that regulates the heater (calcium levels) in a house. If the thermostat is damaged or removed, the heater may not function properly, leading to a drop in temperature (calcium levels). Checking the thermostat (calcium level) is necessary to identify the problem and fix it.

Nurse Laura should promptly check the serum calcium level and notify the healthcare provider of the findings. If hypocalcemia is confirmed, calcium supplements or IV calcium gluconate may be required to manage the condition.

• Monitor the patient's serum calcium levels regularly post-thyroidectomy.
• Observe for other signs of hypocalcemia, such as Chvostek's sign (facial twitching when tapping the facial nerve) and Trousseau's sign (carpopedal spasm with blood pressure cuff inflation).
• Administer calcium supplements or IV calcium as prescribed if hypocalcemia is confirmed.
• Educate the patient about the symptoms of hypocalcemia and the importance of reporting them immediately.
• Ensure close follow-up with the healthcare provider to monitor calcium levels and adjust treatment as needed.

✘ Incorrect answer options:

Bring a crash cart to the bedside. This action is unnecessary unless the patient is showing signs of severe hypocalcemia leading to life-threatening symptoms, such as seizures or cardiac arrhythmias. The priority is to check and address the calcium level first.

Inspect the surgical dressing for drainage. While inspecting the surgical site is important for monitoring for infection or bleeding, it does not address the immediate concern of tingling, which is more likely related to hypocalcemia.

Measure the patient's blood pressure for signs of hypertension. Hypertension is not typically associated with the symptoms of tingling around the mouth and extremities. The priority is to check calcium levels, as these symptoms strongly suggest hypocalcemia.

EXPLANATION

✔ Correct answer:

Monitoring blood glucose levels. When treating a patient with Addison's disease who is receiving IV glucocorticoids like Solu-Medrol, it is crucial to monitor blood glucose levels. Glucocorticoids can cause significant increases in blood glucose, leading to hyperglycemia. This is especially important in patients with Addison's disease, as their adrenal insufficiency makes them more sensitive to the effects of glucocorticoids and more prone to metabolic imbalances.

Addison's disease is characterized by insufficient production of adrenal hormones, including cortisol. During stress or illness, patients with Addison's disease often require exogenous glucocorticoids to prevent adrenal crisis. However, glucocorticoids increase blood glucose by promoting gluconeogenesis and reducing cellular uptake of glucose, necessitating regular monitoring to prevent complications such as hyperglycemia.

Think of blood glucose levels as the speed of a car. Glucocorticoids act like pressing the accelerator. Just as you need to monitor the car's speed to prevent going too fast, you need to monitor blood glucose levels to prevent hyperglycemia.

Nurse Brian should regularly check Mrs. Anderson's blood glucose levels and adjust her care plan based on these readings. This might involve administering insulin if necessary and coordinating with the healthcare team to ensure balanced glucose levels.

• Check blood glucose levels before meals and at bedtime, or as per the facility's protocol.
• Report any significantly elevated glucose levels to the healthcare provider for potential adjustment of medication.
• Educate Mrs. Anderson about the signs and symptoms of hyperglycemia and the importance of blood glucose monitoring.
• Ensure the patient has access to adequate hydration to help manage blood glucose levels.
• Collaborate with a dietitian to provide a balanced diet that supports blood glucose control.

✘ Incorrect answer options:

Encouraging oral fluid intake. While maintaining hydration is important, especially after nausea and vomiting, it is secondary to monitoring blood glucose in a patient receiving high doses of glucocorticoids.

Administering anti-nausea medication. Managing nausea is important for comfort and preventing further dehydration, but it does not address the primary risk of hyperglycemia associated with glucocorticoid therapy.

Checking for signs of infection. Infection monitoring is critical, especially in immunocompromised patients. However, in the context of immediate post-glucocorticoid administration, monitoring blood glucose levels takes precedence to prevent acute metabolic complications.

EXPLANATION

✔ Correct answer:

The patient's blood pressure. After a unilateral adrenalectomy, monitoring the patient's blood pressure is crucial. The adrenal glands produce hormones like aldosterone and cortisol, which play significant roles in regulating blood pressure and electrolyte balance. Removing one adrenal gland can lead to fluctuations in hormone levels, potentially causing hypotension or hypertension. Monitoring blood pressure helps detect these changes early and allows for prompt intervention to stabilize the patient.

The adrenal glands are involved in the secretion of aldosterone, which regulates sodium and potassium balance and, consequently, blood pressure. Postoperative fluctuations in hormone levels can lead to imbalances that significantly affect the cardiovascular system. Ensuring stable blood pressure is critical to prevent complications such as shock or hypertensive crises.

Think of the adrenal glands as a thermostat controlling the water pressure in a plumbing system. Removing one thermostat can cause the pressure to become unstable. Monitoring the water pressure closely ensures it doesn't get too high or too low, preventing leaks or bursts.

Nurse Taylor should measure and document the patient's blood pressure frequently and watch for signs of hypo- or hypertension. Interventions may include adjusting IV fluids, administering medications to manage blood pressure, and assessing for symptoms of adrenal insufficiency.

• Check blood pressure every 15 minutes during the immediate postoperative period, then gradually extend the interval as the patient stabilizes.
• Monitor for signs of hypotension (dizziness, weakness) or hypertension (headache, blurred vision) and report these findings immediately.
• Administer IV fluids or medications as prescribed to maintain stable blood pressure.
• Assess for symptoms of adrenal insufficiency, such as fatigue, abdominal pain, and electrolyte imbalances.
• Educate the patient about the importance of monitoring blood pressure and recognizing symptoms that require medical attention.

✘ Incorrect answer options:

The patient's temperature. Monitoring temperature is important for detecting infections, but it is not the most critical measurement in the immediate postoperative period following adrenalectomy.

The patient's urine output. Although urine output is important for assessing renal function and fluid balance, it is secondary to blood pressure monitoring, as significant blood pressure changes can quickly lead to life-threatening complications.

The specific gravity of the urine. Specific gravity provides information about the concentration of urine, which is useful for assessing hydration status and renal function. However, it is not the immediate priority in the postoperative period compared to monitoring blood pressure.

EXPLANATION

✔ Correct answer:

Pinch the soft lower part of the nose and hold for at least 5 minutes. For a patient with hemophilia, managing a nosebleed effectively and safely is crucial due to their increased risk of prolonged bleeding. The most appropriate initial action is to pinch the soft lower part of the nose and hold it for at least 5 minutes. This action applies direct pressure to the source of the bleeding, which helps to control it by promoting clot formation.

Hemophilia is a genetic disorder that impairs the blood's ability to clot due to the deficiency of clotting factors. This results in prolonged bleeding even from minor injuries. Direct pressure is a fundamental first aid measure to control bleeding in hemophilia patients.

Think of the nosebleed as a small leak in a hose. Pinching the hose near the leak temporarily stops the flow of water, giving time for a patch (clot) to form and seal the leak.

After applying pressure to control the bleeding, Nurse Kelly should continue to monitor the patient for any signs of persistent bleeding or other complications. If the bleeding does not stop, further medical intervention may be required, such as the administration of clotting factor replacement therapy.

• Instruct the patient to breathe through their mouth while pinching the nose to avoid swallowing blood.
• Advise the patient to avoid blowing their nose or inserting anything into the nostrils for several hours after the bleeding stops.
• Monitor the patient for any signs of hypovolemia or anemia if the bleeding is significant or recurrent.
• Educate the patient and family on recognizing early signs of bleeding and the importance of seeking prompt medical attention.
• Ensure the patient has access to and understands how to use any prescribed clotting factor replacement products.

✘ Incorrect answer options:

Position the client in a sitting position with the head hyperextended. Hyperextending the head can cause blood to flow down the throat, leading to swallowing of blood, which can irritate the stomach and potentially lead to vomiting.

Tightly pack the nares with gauze to exert pressure on the bleeding source. While packing can be used in severe cases, it is not the initial recommended action due to the risk of further trauma to the nasal tissues and potential complications in hemophilia patients.

Place ice packs on the forehead and the back of the neck. While ice packs can help constrict blood vessels and reduce bleeding, they are not as effective as direct pressure in stopping an active nosebleed and are not recommended as the primary intervention.

EXPLANATION

✔ Correct answer:

Assess the patient's vital signs. In a patient with diabetes insipidus (DI) presenting with excessive urination, intense thirst, and mental confusion, it is crucial to first assess the patient's vital signs. This helps to determine the current hemodynamic status and identify any signs of dehydration or shock, which can be life-threatening. Vital signs will provide immediate information on blood pressure, heart rate, and overall circulatory status, guiding subsequent interventions.

DI leads to impaired renal water reabsorption, causing excessive urination and severe dehydration. This can result in hypotension, tachycardia, and electrolyte imbalances, which are critical to detect and address promptly.

Think of assessing vital signs like checking the dashboard of a car when the warning light comes on. Before you can fix the problem, you need to see if the engine (heart rate), fuel level (blood pressure), and temperature (body temperature) are within safe ranges to determine the severity of the issue.

Once vital signs are assessed, further actions can be taken based on the findings. If signs of dehydration or hemodynamic instability are present, rapid intervention with fluid replacement and electrolyte management can be initiated.

• Monitor the patient's vital signs regularly to detect changes promptly.
• Initiate IV fluid therapy as prescribed to correct dehydration and stabilize blood pressure.
• Check serum electrolyte levels to identify and correct imbalances, particularly sodium levels.
• Educate the patient on the importance of medication adherence to manage DI and prevent complications.
• Document all findings and interventions to ensure continuity of care.

✘ Incorrect answer options:

Monitor the patient's urinary output. While this is important to evaluate the extent of diuresis and response to treatment, it does not immediately address the potential hemodynamic instability caused by DI.

Promote an increase in fluid intake. Encouraging fluid intake is essential, but assessing vital signs takes precedence to ensure the patient is stable enough to manage increased fluid intake safely.

Weigh the patient. Daily weights help monitor fluid status over time but are not the immediate priority in a potentially unstable patient presenting with signs of severe dehydration and mental confusion.

EXPLANATION

✔ Correct answer:

Elevate the head of the bed to a 30-degree angle. After a transsphenoidal hypophysectomy, it is essential to manage intracranial pressure (ICP) and promote proper drainage to prevent complications such as cerebrospinal fluid (CSF) leaks and to facilitate healing. Elevating the head of the bed to a 30-degree angle helps reduce ICP, enhances venous return, and decreases the risk of post-operative complications such as headaches and CSF leaks.

The transsphenoidal approach involves accessing the pituitary gland through the sphenoid sinus. Post-operative care focuses on minimizing pressure in the surgical area, preventing CSF leakage, and ensuring proper healing of the surgical site.

Imagine the brain and the surrounding fluids as a water balloon placed inside a box. If the balloon is pressed from any direction, the pressure inside increases, risking a rupture. Elevating the head of the bed is like slightly tilting the box so the water settles evenly, relieving pressure on the balloon and preventing it from bursting.

Nurses should ensure the patient’s head is elevated to 30 degrees consistently. They should also monitor for signs of increased ICP, CSF leaks, and other post-operative complications.

• Monitor neurological status regularly, including level of consciousness and pupil responses.
• Check for signs of CSF leakage, such as clear fluid drainage from the nose or a salty taste in the mouth.
• Instruct the patient to avoid activities that increase ICP, such as straining, coughing, or bending over.
• Administer prescribed medications to manage pain and prevent infection.
• Encourage adequate hydration and nutrition to support recovery.

✘ Incorrect answer options:

Position the patient in Trendelenburg for postural drainage. The Trendelenburg position (where the patient’s head is lower than their feet) is contraindicated in this scenario as it can increase ICP and lead to complications, such as CSF leaks or increased bleeding.

Promote coughing and deep breathing exercises every 2 hours. While deep breathing exercises are generally beneficial, promoting coughing can increase ICP and the risk of CSF leaks. Gentle breathing exercises without forced coughing are preferred to maintain oxygenation without straining.

Advise the patient to perform the Valsalva maneuver during bowel movements. The Valsalva maneuver increases intrathoracic pressure and consequently ICP, which is harmful post-surgery. Instead, patients should be advised to use stool softeners and avoid straining.

EXPLANATION

✔ Correct answer:

Bleeding precautions. In autoimmune thrombocytopenic purpura (ITP), the platelet count is low, which significantly increases the risk of bleeding. With a platelet count of 80,000/µL (lower than the normal range of 150,000-450,000/µL), it is crucial to teach James and his family about bleeding precautions to prevent potential hemorrhage. These precautions are essential to minimize the risk of bleeding from minor injuries, cuts, or spontaneous bleeding.

Platelets are critical for blood clotting. In ITP, the immune system destroys platelets, leading to thrombocytopenia (low platelet count). This condition impairs the blood's ability to form clots, making individuals more susceptible to bleeding.

Think of platelets as the “band-aids” of the blood. Without enough band-aids, even small cuts or injuries can continue to bleed. Teaching bleeding precautions is like instructing someone on how to avoid getting cuts and how to handle them safely if they occur.

Nurses should educate patients and their families about the importance of avoiding activities that can cause injuries, the signs of bleeding to watch for, and the steps to take if bleeding occurs. This includes avoiding medications that can further affect platelet function, such as NSAIDs.

• Encourage the use of a soft toothbrush and electric razor to prevent gum and skin bleeding.
• Advise against contact sports or other activities that might result in trauma.
• Instruct on safe handling of sharp objects and using protective gear as needed.
• Inform about signs of internal bleeding, such as black or bloody stools, and when to seek immediate medical attention.
• Review medications and avoid those that can exacerbate bleeding risk, like aspirin and other NSAIDs.

✘ Incorrect answer options:

Prevention of falls. While fall prevention is important, particularly in individuals at risk of bleeding, it is a subset of the broader category of bleeding precautions. Teaching comprehensive bleeding precautions includes fall prevention strategies.

Oxygen therapy. Oxygen therapy is not relevant to the management of ITP, as it does not address the underlying issue of low platelet count or the risk of bleeding.

Conservation of energy. Although important in chronic conditions to avoid fatigue, energy conservation does not directly address the primary risk associated with ITP, which is bleeding due to low platelet count.

EXPLANATION

✔ Correct answer:

The platelet count. Autoimmune thrombocytopenic purpura (ITP) is a condition characterized by an abnormally low level of platelets due to the body's immune system attacking its own platelets. Monitoring the platelet count is crucial for evaluating the effectiveness of treatment, as the primary goal is to increase the platelet count to a safe level. A rising platelet count indicates a positive response to therapy, while a falling count may suggest the need for a change in the treatment plan.

In ITP, antibodies target and destroy platelets, leading to their decreased number in the blood. Platelets are essential for blood clotting and preventing excessive bleeding. Treatments aim to suppress the immune system’s destruction of platelets or to stimulate platelet production.

Imagine the platelets as bricks needed to build a wall (blood clot) to stop leaks (bleeding). In ITP, the immune system acts like a wrecking ball that keeps knocking down the bricks. Monitoring the number of bricks (platelet count) helps determine if the measures taken to stop the wrecking ball are working and if the wall can be built properly.

Nurses should regularly monitor the patient's platelet count through blood tests. Additionally, nurses should observe for signs of bleeding, such as bruising, petechiae (small red or purple spots), and bleeding gums, which can indicate a low platelet count.

• Educate the patient about the importance of regular blood tests to monitor platelet levels.
• Encourage the patient to report any unusual bleeding or bruising immediately.
• Administer prescribed medications such as corticosteroids or immunoglobulins to increase platelet counts.
• Provide information on safe practices to minimize the risk of bleeding, such as using a soft toothbrush and avoiding contact sports.
• Support the patient emotionally and provide resources for coping with the chronic nature of the condition.

✘ Incorrect answer options:

The white blood cell count. While the white blood cell count is important in many conditions, it is not the primary focus in ITP. Monitoring white blood cells is more relevant for conditions involving infection or immune disorders affecting white blood cells directly.

Potassium levels in the blood. Potassium levels are critical to monitor in conditions affecting the kidneys or heart, but they are not directly related to the evaluation of treatment efficacy in ITP.

Partial prothrombin time (PTT). PTT is used to evaluate the blood's ability to clot and monitor anticoagulation therapy. While it is important in conditions involving coagulation disorders, it is not specific for monitoring platelet count or the response to treatment in ITP.

EXPLANATION

✔Correct answer:

Risk for infection. The priority nursing diagnosis for Tom, a 22-year-old male with Hodgkin's lymphoma, should be "Risk for infection." Hodgkin's lymphoma and its treatment, which often includes chemotherapy and radiation, can significantly suppress the immune system, making patients highly susceptible to infections. This risk is immediate and life-threatening, necessitating proactive measures to protect the patient from potential infections.

Hodgkin's lymphoma is a type of cancer that originates in the lymphatic system. The disease, along with its treatments, can lead to immunosuppression by affecting white blood cell counts and function, leaving the patient vulnerable to infections. Managing this risk is crucial to prevent complications that can severely impact the patient's health and treatment outcomes.

Imagine a castle with weakened walls (immune system) due to ongoing repairs (cancer treatment). It becomes critical to guard against invaders (infections) that can easily breach the compromised defenses.

Nurses should implement infection control measures, educate the patient on infection prevention, and closely monitor for signs of infection. This includes:

• Maintaining strict hand hygiene and encouraging the patient and visitors to do the same.
• Ensuring the patient avoids contact with individuals who are sick or have infections.
• Monitoring vital signs and lab results for early detection of infection (e.g., fever, elevated white blood cell count).
• Educating the patient on the importance of promptly reporting symptoms of infection, such as fever, chills, or sore throat.
• Providing vaccinations as recommended (avoiding live vaccines if immunocompromised) and prophylactic medications if prescribed.
• Implementing neutropenic precautions if the patient has low neutrophil counts.

✘Incorrect answer options:

Disturbed body image. While this is an important concern, especially for a young adult, it is not as immediate and life-threatening as the risk of infection. Addressing body image issues can be important for long-term psychological well-being but is secondary to preventing infection.

Ineffective role performance. This diagnosis addresses the impact of illness on the patient's ability to fulfill his roles, such as being a student, fiancé, and employee. While significant, it is not as critical as preventing infections, which can have immediate and severe health consequences.

Anticipatory grieving. This diagnosis pertains to the emotional response to potential loss related to illness. It is important to support the patient through these feelings, but the priority should be managing the immediate physical risks, such as infection, to ensure the patient remains healthy enough to address these psychosocial concerns.

EXPLANATION

✔Correct answer:

Risk for injury related to thrombocytopenia. The priority nursing diagnosis for an adult client with acute leukemia should be "Risk for injury related to thrombocytopenia." Thrombocytopenia, a condition characterized by a low platelet count, is common in clients with acute leukemia due to the disease's impact on bone marrow function. This significantly increases the risk of bleeding and injury, making it a critical concern that requires immediate attention and intervention.

Acute leukemia disrupts normal hematopoiesis in the bone marrow, leading to decreased production of platelets, which are essential for blood clotting. Thrombocytopenia puts patients at high risk for spontaneous bleeding, including severe internal hemorrhage, which can be life-threatening. Managing this risk is essential to prevent complications and ensure patient safety.

Think of platelets as the "band-aids" of the bloodstream. When there aren't enough band-aids, even minor injuries can become serious because there's nothing to stop the bleeding.

Nurses should focus on strategies to prevent injury and manage thrombocytopenia. This includes monitoring platelet counts, educating patients on avoiding activities that could lead to injury, and implementing safety measures.

• Regularly monitor platelet counts and assess for signs of bleeding, such as bruising, petechiae, and prolonged bleeding from minor cuts.
• Educate the patient to avoid activities that could cause injury, such as contact sports or using sharp objects.
• Implement safety measures, such as using soft-bristle toothbrushes, electric razors, and avoiding intramuscular injections when possible.
• Ensure the patient avoids medications that can exacerbate bleeding, like aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs).
• Coordinate with the healthcare team for possible platelet transfusions if necessary.

✘Incorrect answer options:

Altered oral mucous membrane related to chemotherapy. While this is a relevant concern, particularly due to the side effects of chemotherapy causing mucositis or mouth sores, it is not as immediately life-threatening as the risk of injury from thrombocytopenia.

Fatigue related to the disease process. Fatigue is a common and significant symptom in clients with acute leukemia. However, it does not pose an immediate risk to the patient's safety compared to the risk of injury from thrombocytopenia.

Interrupted family processes related to the life-threatening illness of a family member. This diagnosis addresses the psychosocial impact of acute leukemia on the family, which is important for holistic care. However, it is not the immediate priority compared to addressing the physical safety and risk of life-threatening complications in the patient.

EXPLANATION

✔Correct answer:

"Have you experienced any respiratory infections in the past six months?" This question is the most important for Nurse Julia to ask because individuals with acute leukemia are at a high risk for infections due to their compromised immune system. Acute leukemia can significantly reduce the number and functionality of white blood cells, which are crucial for fighting infections. Assessing for recent respiratory infections can help identify if the patient has been experiencing immune-related complications, which is critical for managing their condition effectively.

Acute leukemia is characterized by the rapid proliferation of abnormal white blood cells, which crowd out normal blood cells in the bone marrow. This leads to a deficiency in functional white blood cells, resulting in immunosuppression and an increased susceptibility to infections. Respiratory infections are particularly concerning because they can quickly become severe in immunocompromised patients.

Think of the immune system as a defense army protecting a city. In acute leukemia, the army is significantly weakened, making it easier for invaders (infections) to breach the defenses (the body).

Nurses should conduct a thorough health history to identify recent infections and implement appropriate infection control measures. This includes monitoring for signs of infection, educating the patient about infection prevention, and coordinating with the healthcare team for timely interventions.

• Ask about any recent infections, particularly respiratory infections, to assess the patient's current health status and risk of complications.
• Monitor vital signs and laboratory results, such as white blood cell counts and cultures, to detect infections early.
• Implement strict infection control measures, including hand hygiene, isolation protocols if necessary, and the use of personal protective equipment (PPE).
• Educate the patient and family about the importance of infection prevention, including avoiding crowds and individuals with infections.
• Coordinate with the healthcare team to provide prompt treatment for any identified infections, including antibiotics or antifungal medications as needed.

✘Incorrect answer options:

"Have you noticed any recent changes in your sleeping habits?" While sleep disturbances can occur in individuals with acute leukemia due to factors like pain, anxiety, or treatment side effects, this question is not as critical as assessing for recent infections.

"Have you had any recent weight loss?" Weight loss can be a symptom of acute leukemia, but it is not as immediately concerning as recent infections, which can have more immediate and severe implications for the patient's health.

"Have you observed any changes in your level of alertness?" Changes in alertness can be significant, particularly if they indicate central nervous system involvement or severe anemia. However, assessing for recent infections provides more direct information about the patient's current risk for complications and helps guide immediate interventions.

EXPLANATION

✔Correct answer:

Oral mucosa. The best site for Nurse Alex to examine for the presence of petechiae in an African American client is the oral mucosa. Petechiae are small, red or purple spots caused by bleeding under the skin and mucous membranes. In individuals with darker skin tones, petechiae may be more challenging to detect on highly pigmented areas. The oral mucosa, being less pigmented and more consistent in coloration, provides a clearer contrast for observing these tiny hemorrhages.

Petechiae result from the rupture of small blood vessels (capillaries), leading to minor bleeding under the skin or mucous membranes. In acute leukemia, thrombocytopenia (a reduced platelet count) is common, significantly increasing the risk of bleeding and the development of petechiae. The oral mucosa offers an excellent site for detection due to its lighter and more uniform coloration compared to the skin.

Imagine trying to spot red ink dots on a dark versus a light-colored surface. The lighter surface (oral mucosa) makes the red dots (petechiae) more noticeable compared to the darker surface.

Nurses should conduct a thorough examination of the oral mucosa and other less pigmented areas to monitor for signs of bleeding in patients with acute leukemia. Early detection and documentation of petechiae are crucial for managing and preventing complications associated with bleeding disorders.

• Inspect the oral mucosa for petechiae and other signs of bleeding.
• Examine additional areas such as the conjunctiva and palmar creases for petechiae.
• Monitor platelet counts and coagulation parameters regularly to assess bleeding risk.
• Educate patients about the signs of bleeding and the importance of reporting any new or worsening symptoms immediately.
• Implement safety measures to reduce the risk of injury and bleeding, such as using soft toothbrushes and avoiding sharp objects.

✘Incorrect answer options:

Palms of the hands. While the palms may be less pigmented than other areas, they still may not provide the best contrast for observing petechiae, particularly in individuals with darker skin tones.

Soles of the feet. The soles of the feet are often highly pigmented and have thicker skin, making it more difficult to detect petechiae in this area.

Abdomen. The abdomen is a commonly checked site for petechiae, but in individuals with darker skin tones, the pigmentation may make it more challenging to identify these small hemorrhages. The oral mucosa remains the more reliable site for detection.

EXPLANATION

✔Correct answer:

The client received radiation treatment for Hodgkin's disease as a teenager. A history of receiving radiation treatment for Hodgkin's disease is a significant factor to inquire about when assessing for possible acute leukemia. Previous radiation therapy is a known risk factor for the development of secondary malignancies, including leukemia. This information is crucial in understanding John's medical history and evaluating his current condition.

Acute leukemia involves the rapid proliferation of abnormal white blood cells, which crowd out normal cells in the bone marrow. Exposure to radiation can cause mutations in the DNA of hematopoietic stem cells, increasing the risk of developing leukemia. Individuals who have undergone radiation therapy, especially at a young age, are at higher risk for secondary cancers later in life.

Think of radiation exposure as a wildfire that can damage healthy trees (cells) in a forest. Even after the fire is out, the damaged area remains vulnerable to new growths (cancers) that can spread quickly.

Nurses should conduct a thorough health history to identify potential risk factors for leukemia, including prior radiation therapy. This helps in forming a comprehensive understanding of the patient's condition and guiding further diagnostic testing and management.

• Inquire about any history of radiation therapy, chemotherapy, or exposure to other carcinogens.
• Assess for symptoms commonly associated with leukemia, such as fatigue, frequent infections, easy bruising or bleeding, and unexplained weight loss.
• Document any family history of hematological disorders or cancers, as this can also provide relevant information.
• Educate the patient on the importance of regular follow-ups and monitoring for signs and symptoms of leukemia.
• Collaborate with the healthcare team to plan and implement appropriate diagnostic tests, such as blood tests and bone marrow biopsy.

✘Incorrect answer options:

The client collects stamps as a hobby. This information is unrelated to the assessment of leukemia and does not provide any relevant medical history or risk factors for the disease.

The client recently lost his job as a postal worker. While significant life events such as job loss can affect overall well-being and stress levels, this information is not directly related to the risk or assessment of leukemia.

The client's brother had leukemia during childhood. While a family history of leukemia can be relevant, especially in identifying hereditary syndromes or genetic predispositions, the more immediate and impactful factor to assess is the client's own medical history of radiation exposure.

EXPLANATION

✔Correct answer:

"I will limit my fluid intake to 500mL or less each day." This statement indicates a need for further teaching. Clients with polycythemia vera should not limit their fluid intake to such a low level. In fact, adequate hydration is crucial for preventing complications associated with polycythemia vera. Sufficient fluid intake helps maintain blood volume and viscosity, reducing the risk of thrombosis, which is a common complication of this condition.

Polycythemia vera is a myeloproliferative disorder characterized by an increase in red blood cell mass, which leads to increased blood viscosity and volume. This can result in a higher risk of thrombosis (blood clots). Proper hydration helps to dilute the blood and reduce its viscosity, thereby minimizing the risk of clot formation.

Think of blood like a thick syrup. If you add water, it becomes thinner and flows more easily. Without enough water, the syrup stays thick and is more likely to clog or stick to the container (blood vessels).

Nurses should educate clients with polycythemia vera on the importance of maintaining adequate hydration, using support measures to reduce the risk of clot formation, and avoiding activities that could lead to bleeding or injury.

• Encourage clients to drink plenty of fluids, aiming for at least 2-3 liters per day unless contraindicated by other medical conditions.
• Instruct clients to avoid dehydration, especially during hot weather or while exercising.
• Advise the use of support hose to improve circulation and reduce the risk of venous stasis.
• Recommend using an electric razor to minimize the risk of cuts and bleeding.
• Suggest choosing foods that are low in iron to prevent further increases in red blood cell production.

✘Incorrect answer options:

"I will wear support hose when I am up and about." Wearing support hose helps improve venous return and reduce the risk of venous stasis and thrombosis, which are significant concerns in polycythemia vera.

"I will use an electric razor for shaving to avoid cuts." Using an electric razor reduces the risk of cuts and bleeding, which is important for individuals with polycythemia vera due to their increased blood viscosity and potential for excessive bleeding.

"I will choose foods that are low in iron." Selecting foods low in iron helps prevent further increases in red blood cell production, which can exacerbate the symptoms and complications of polycythemia vera.

EXPLANATION

✔Correct answer:

Shallow respirations at a rate of 28 breaths per minute. An increased respiratory rate, especially shallow breathing, is a common compensatory mechanism in anemia. When hemoglobin levels are low, the body's ability to carry oxygen is diminished. To compensate, the body increases the respiratory rate to maximize oxygen intake and delivery to tissues. Shallow, rapid breathing is indicative of the body's effort to counteract hypoxia associated with anemia.

Anemia results in reduced oxygen-carrying capacity of the blood due to a decrease in the number or function of red blood cells or hemoglobin. The body compensates for this deficit by increasing heart rate and respiratory rate in an attempt to deliver more oxygen to tissues.

Imagine a delivery truck (hemoglobin) that carries oxygen packages to various parts of the city (the body). If the truck can carry fewer packages (due to anemia), it will have to make more trips (increased breathing rate) to deliver the same amount of oxygen.

Nurses should monitor vital signs, including respiratory rate, in clients with anemia. Providing supplemental oxygen and educating clients about managing symptoms and underlying causes of anemia are essential components of care.

• Monitor respiratory rate and pattern in clients with anemia.
• Assess for other signs and symptoms of anemia, such as fatigue, pallor, and tachycardia.
• Provide oxygen therapy as prescribed to alleviate hypoxia.
• Educate clients on the importance of adhering to treatment plans, including dietary modifications and supplementation if necessary.
• Encourage regular follow-up appointments to monitor hemoglobin levels and overall health.

✘Incorrect answer options:

Blood pressure reading of 146/88. Elevated blood pressure is not typically associated with anemia. In fact, anemia often leads to lower blood pressure due to decreased blood volume and oxygen-carrying capacity. Hypertension could indicate other health issues, but it is not a primary indicator of anemia.

Weight gain of 10 pounds over 6 months. Weight gain is not a direct clinical manifestation of anemia. Changes in weight are more commonly related to nutritional intake, metabolic conditions, or other health issues. Anemia more commonly leads to symptoms like fatigue and weakness rather than weight changes.

Pink complexion. A pink complexion indicates adequate oxygenation and blood flow, which is generally not consistent with anemia. Anemia typically results in pallor or a pale appearance due to reduced hemoglobin levels and oxygen-carrying capacity.

EXPLANATION

✔Correct answer:

Sclera of the eyes. The sclera, or the white part of the eyes, is the best place to check for jaundice, especially in individuals with darker skin tones. Jaundice results from elevated levels of bilirubin in the blood, which causes a yellowish discoloration of the skin and mucous membranes. The sclera is less affected by pigmentation and provides a more accurate indication of jaundice.

Jaundice occurs when there is an accumulation of bilirubin, a byproduct of the breakdown of red blood cells. In vitamin B12 deficiency anemia, ineffective erythropoiesis and increased destruction of defective red blood cells can lead to elevated bilirubin levels. The yellowing of the sclera is due to bilirubin depositing in the tissues.

Think of bilirubin as a yellow dye. If a white cloth (the sclera) is stained with this dye, the yellow color is very noticeable. In contrast, if a dark cloth (pigmented skin) is stained, the color change is less obvious.

Nurses should assess for jaundice by examining the sclera, especially in patients with darker skin tones. Additionally, educating patients on the signs and symptoms of vitamin B12 deficiency and the importance of dietary intake or supplementation is crucial for management and prevention.

• Examine the sclera for yellow discoloration as an indicator of jaundice.
• Assess other areas less affected by pigmentation, such as the mucous membranes inside the mouth.
• Monitor for other symptoms of vitamin B12 deficiency, including fatigue, pallor, glossitis, and neurological changes.
• Educate patients on sources of vitamin B12, such as meat, eggs, dairy products, and fortified cereals, as well as the potential need for supplements or injections.
• Encourage regular follow-ups and blood tests to monitor vitamin B12 levels and overall health.

✘Incorrect answer options:

Fingernails. Fingernails can sometimes reflect overall health, but they are not reliable indicators of jaundice. The yellowing of the nails can be due to various other factors and is less specific for detecting elevated bilirubin levels.

Palms of the hands. While palms can show signs of pallor in anemia, they are not the best indicators of jaundice, especially in individuals with darker skin tones where the pigmentation can obscure yellow discoloration.

Soles of the feet. Similar to the palms, the soles of the feet are not the best places to check for jaundice due to pigmentation. They can also be influenced by other factors, making them less reliable for detecting bilirubin-related changes.

EXPLANATION

✔Correct answer:

Examine the tongue. Vitamin B12 deficiency often leads to glossitis, which is inflammation of the tongue. This condition can cause the tongue to appear red, swollen, and smooth. Examining the tongue is an important part of the physical assessment for clients with suspected or known vitamin B12 deficiency, as it provides visible signs of the condition.

Vitamin B12 is essential for DNA synthesis and red blood cell formation. A deficiency can lead to megaloblastic anemia, where red blood cells are larger than normal and not properly formed. One of the common symptoms of vitamin B12 deficiency is glossitis, which is often accompanied by other symptoms like fatigue, pallor, and neurological changes due to the role of vitamin B12 in nerve function.

Imagine vitamin B12 as a key ingredient in a recipe. If this ingredient is missing, the final dish (the body's health) won't turn out right, and you might notice changes in the appearance of the dish (the tongue's condition).

Nurses should conduct a comprehensive physical assessment, including an examination of the tongue, to identify signs of vitamin B12 deficiency. They should also educate clients on the importance of dietary sources of vitamin B12 and monitor for neurological symptoms that can indicate a more severe deficiency.

• Inspect the tongue for signs of glossitis, such as redness, swelling, and a smooth texture.
• Assess for other symptoms of anemia, such as pallor, fatigue, and shortness of breath.
• Monitor for neurological symptoms, including numbness, tingling, and balance issues, which can occur with severe vitamin B12 deficiency.
• Educate clients about vitamin B12-rich foods, such as meat, eggs, dairy products, and fortified cereals.
• Discuss the potential need for vitamin B12 supplements or injections if dietary intake is insufficient or absorption is impaired.

✘Incorrect answer options:

Palpate the spleen. While splenomegaly (enlarged spleen) can occur with certain types of anemia, it is not a common finding in vitamin B12 deficiency. Palpating the spleen would be more relevant in conditions like hemolytic anemia or other hematological disorders.

Measure the blood pressure. Measuring blood pressure is a standard part of any physical assessment, but it is not specific to diagnosing or assessing vitamin B12 deficiency. Blood pressure measurement does not provide direct information about vitamin B12 status.

Inspect the feet for petechiae. Petechiae (small red or purple spots caused by bleeding under the skin) are typically associated with platelet disorders or other clotting issues, not with vitamin B12 deficiency. Inspecting for petechiae would be more relevant in conditions like thrombocytopenia.

EXPLANATION

✔Correct answer:

Going on a bus trip to the Museum of Natural History. This activity does not involve significant changes in altitude or environmental conditions that could lead to hypoxia or hypoxemia. A bus trip to a museum is generally a low-risk activity for individuals with sickle cell anemia, as it avoids factors like reduced oxygen levels that are associated with high altitudes or cold weather.

Sickle cell anemia is characterized by the presence of abnormal hemoglobin (HbS) in red blood cells, which causes the cells to take on a rigid, sickle shape. These misshapen cells can obstruct blood flow and lead to episodes of pain and organ damage, particularly under conditions of low oxygen (hypoxia), dehydration, or extreme temperatures. Hypoxemia (low blood oxygen levels) can trigger a sickle cell crisis, making it essential to avoid activities that could reduce oxygen availability.

Think of sickle cell anemia like a fragile glass object that can crack under pressure. Just as you would avoid dropping or squeezing the glass, a person with sickle cell anemia should avoid situations that stress their body and reduce oxygen, which can trigger a crisis.

Nurses should educate clients on avoiding activities that can precipitate hypoxia or hypoxemia and provide guidelines for managing their condition effectively. Monitoring and regular follow-up are also important for managing sickle cell anemia.

• Educate clients about the risks of high altitudes and extreme temperatures.
• Encourage staying well-hydrated and avoiding strenuous activities that can lead to dehydration or hypoxia.
• Advise on the importance of regular medical check-ups and adherence to prescribed treatments.
• Provide resources for support and information on managing sickle cell anemia.
• Discuss the importance of recognizing early signs of a sickle cell crisis and seeking prompt medical attention.

✘Incorrect answer options:

Taking a family vacation in the Rocky Mountains. High altitudes can significantly reduce oxygen levels, leading to hypoxia. For someone with sickle cell anemia, this can increase the risk of a sickle cell crisis.

Chaperoning a snow-skiing trip with the local boys' club. Cold temperatures and physical exertion during skiing can lead to hypoxia and dehydration, both of which are risk factors for triggering a sickle cell crisis.

Flying by airplane for business trips. While modern airplanes are pressurized, the cabin pressure is still equivalent to an altitude of about 6,000-8,000 feet, which can reduce oxygen levels and potentially trigger hypoxia in individuals with sickle cell anemia.

EXPLANATION

✔Correct answer:

Spinach salad with strawberries, lentil soup, and whole-grain bread. This meal plan is rich in iron and includes both heme and non-heme iron sources. Spinach and lentils are excellent sources of non-heme iron, while strawberries provide vitamin C, which enhances the absorption of non-heme iron. Whole-grain bread also contains iron and additional nutrients that support overall health. Together, these foods create a balanced meal that maximizes iron intake and absorption.

Iron-deficiency anemia occurs when there is insufficient iron to produce adequate hemoglobin for red blood cells. Hemoglobin is essential for transporting oxygen throughout the body. Adequate dietary iron intake, combined with nutrients that enhance iron absorption, is crucial for managing this condition.

Think of iron as the fuel needed to run a car (your body). If you have a car with a small gas tank (limited iron stores), you need to fill it frequently with high-quality fuel (iron-rich foods) and use additives (vitamin C) to ensure your car runs efficiently (iron absorption).

Nurses should educate clients about the importance of consuming iron-rich foods along with foods high in vitamin C to enhance absorption. Monitoring dietary habits and providing personalized meal plans can help manage and improve iron-deficiency anemia.

• Encourage the consumption of both heme (animal-based) and non-heme (plant-based) iron sources.
• Advise pairing iron-rich foods with vitamin C-rich foods to improve absorption.
• Educate about avoiding foods or substances that inhibit iron absorption, such as calcium-rich foods or caffeine, during iron-rich meals.
• Monitor hemoglobin levels and symptoms of anemia regularly.
• Provide support and resources for dietary planning and adjustments.

✘Incorrect answer options:

Grilled chicken, steamed broccoli, and white rice. While this meal includes some iron (chicken and broccoli), it lacks sufficient vitamin C to enhance non-heme iron absorption. Additionally, white rice is a low-iron food that doesn’t significantly contribute to iron intake.

Cheese omelet, hash browns, and orange juice. This meal provides some iron from the eggs but is high in calcium from the cheese, which can inhibit iron absorption. Although orange juice is high in vitamin C, the overall iron content in this meal is relatively low.

Pasta with Alfredo sauce, garlic bread, and Caesar salad. This meal is low in iron and lacks vitamin C sources. The calcium in the Alfredo sauce and Caesar salad dressing can further inhibit iron absorption, making it unsuitable for someone with iron-deficiency anemia.

EXPLANATION

✔Correct answer:

Initiate oxygen therapy. In a sickle cell crisis, patients experience vaso-occlusive episodes due to sickled red blood cells obstructing blood flow, leading to tissue ischemia and pain. A pulse oximetry reading of 92% indicates that Jason’s oxygen saturation is below the normal range (typically 95-100%). Initiating oxygen therapy is crucial as it helps to increase the oxygen supply to the tissues, reduce hypoxia, and prevent further sickling of red blood cells, thereby addressing both the immediate risk and the pain caused by ischemia.

In sickle cell anemia, low oxygen levels can exacerbate the sickling of red blood cells. These sickled cells can obstruct capillaries, reducing blood flow and oxygen delivery to tissues. Increasing oxygen levels can help to reverse this sickling process, improve tissue oxygenation, and reduce pain and complications associated with vaso-occlusive crises.

Imagine that the tissues in Jason’s body are like a garden. During a sickle cell crisis, the garden isn’t getting enough water (oxygen), causing plants (tissues) to wilt (become ischemic and painful). Providing oxygen is like turning on a sprinkler system, giving the garden the water it needs to recover and thrive.

Nurse Jenna should prioritize interventions that address the immediate needs of improving oxygenation and relieving pain in the patient.

• Initiate oxygen therapy to increase oxygen saturation levels and improve tissue oxygenation.
• Monitor oxygen saturation continuously to ensure it improves with therapy.
• Follow up with additional interventions such as hydration and pain management once oxygen therapy is initiated.
• Educate the patient about the importance of oxygen therapy in managing their condition and preventing further complications.

✘Incorrect answer options:

Adjust the room temperature. Adjusting the room temperature might improve comfort but does not address the immediate need for increased oxygenation. While maintaining a warm environment can prevent vasoconstriction and pain, it is not the priority intervention for a patient with low oxygen saturation.

Administer a bolus of IV fluids. Hydration is critical in a sickle cell crisis to reduce blood viscosity and improve circulation. However, this intervention should follow after addressing the immediate oxygen needs. Initiating oxygen therapy takes precedence over hydration when oxygen saturation is low.

Give 75mg of meperidine (Demerol) IV push. Pain management is essential, but meperidine is generally not the first-line opioid due to its potential for causing neurotoxic side effects, especially in repeated doses. Additionally, while pain relief is crucial, addressing hypoxia with oxygen therapy should be the initial focus to prevent further sickling and complications.

EXPLANATION

✔Correct answer:

A refreshing popsicle. During a sickle cell crisis, maintaining proper hydration is crucial to help reduce blood viscosity and promote circulation. Encouraging the consumption of hydrating foods and fluids can aid in achieving adequate hydration levels. A refreshing popsicle is an excellent choice because it provides both hydration and a soothing effect, which can be beneficial for patients in pain or discomfort.

In sickle cell anemia, the sickled red blood cells can obstruct blood flow, leading to ischemic pain and complications. Hydration helps to decrease blood viscosity, making it easier for blood to flow through the vessels and reducing the likelihood of cells clumping together and causing blockages.

Think of your blood vessels like pipes carrying water. If the water is thick and sluggish, it can cause blockages. Drinking water or consuming hydrating foods like popsicles is like adding more water to thin it out, helping it flow more smoothly through the pipes.

Nurses should emphasize the importance of hydration to patients with sickle cell disease and provide recommendations for hydrating foods and fluids.

• Encourage the consumption of hydrating foods like popsicles, soups, and fruits with high water content.
• Promote regular fluid intake, aiming for at least 2000-3000 mL per day unless contraindicated.
• Monitor the patient’s intake and output to ensure adequate hydration levels.
• Provide patient education on the importance of staying hydrated to manage sickle cell disease effectively.
• Offer a variety of hydrating options to cater to the patient’s preferences and increase compliance.

✘Incorrect answer options:

Fresh peaches. While fresh peaches are healthy and provide some hydration, they are not as hydrating as a popsicle. The focus during a sickle cell crisis should be on maximizing fluid intake, and popsicles offer a higher water content per serving.

A serving of cottage cheese. Cottage cheese is nutritious but does not provide significant hydration. It is important to prioritize foods and fluids that contribute to fluid intake during a sickle cell crisis.

A portion of lima beans. Lima beans are a good source of nutrients and fiber but do not provide substantial hydration. Hydration is key during a sickle cell crisis, so foods with higher water content are preferred.

EXPLANATION

✔Correct answer:

Promoting fluid intake of no less than 200mL per hour. During a sickle cell crisis, one of the primary interventions is to ensure adequate hydration. Promoting fluid intake helps to decrease blood viscosity, improve circulation, and reduce the risk of further sickling of red blood cells. Proper hydration can help prevent vaso-occlusive episodes, which are the main cause of pain and complications in sickle cell crises.

Sickle cell anemia causes red blood cells to become rigid and shaped like a sickle, which can obstruct blood flow and lead to tissue ischemia and pain. Dehydration can exacerbate this condition by increasing blood viscosity, making it easier for sickle cells to clump together and block blood vessels. Ensuring adequate hydration helps to keep the blood less viscous, promoting better circulation and reducing the risk of complications.

Think of your blood vessels like highways. When there is a traffic jam caused by sickle-shaped cells, adding more cars (dehydration) makes it worse. Adding water is like adding more lanes to the highway, allowing cars to move more freely and reducing the jam.

Nurses should focus on maintaining optimal hydration in patients experiencing a sickle cell crisis, as it is crucial for reducing symptoms and preventing further complications.

• Encourage the patient to drink at least 200mL of fluids every hour, if not contraindicated.
• Monitor intake and output to ensure the patient is adequately hydrated.
• Administer IV fluids as prescribed to maintain hydration.
• Educate the patient about the importance of hydration in managing sickle cell disease.
• Assess for signs of fluid overload, especially in patients with concurrent health issues such as heart failure.

✘Incorrect answer options:

Measuring blood pressure every hour using a mechanical cuff. While monitoring vital signs, including blood pressure, is important, it is not the top priority in managing a sickle cell crisis. Frequent blood pressure measurements alone do not directly alleviate the acute symptoms or prevent complications of a sickle cell crisis.

Positioning in high Fowler's with knees slightly elevated. Positioning can help with comfort and breathing, but it is not the primary intervention for a sickle cell crisis. Ensuring adequate hydration is more critical for preventing further sickling and managing the crisis.

Administering Tylenol as prescribed. While pain management is important in a sickle cell crisis, hydration takes precedence. Tylenol (acetaminophen) can help with mild pain relief, but it does not address the underlying issue of reduced blood flow caused by sickling cells. Other pain management strategies, including stronger analgesics, may also be required.

EXPLANATION

✔Correct answer:

Administering prescribed opioid analgesics. Sickle cell crisis is characterized by severe, often excruciating pain caused by the obstruction of blood flow due to the sickling of red blood cells. This vaso-occlusive crisis results in ischemia and damage to tissues, necessitating effective and prompt pain management. Opioid analgesics are the cornerstone of pain management during a sickle cell crisis because of their potent efficacy in relieving severe pain quickly and effectively.

During a sickle cell crisis, the abnormally shaped red blood cells block small blood vessels, leading to tissue ischemia and significant pain. Opioids work by binding to specific receptors in the brain and spinal cord, inhibiting pain pathways and providing substantial pain relief.

Think of the severe pain in a sickle cell crisis like an alarm going off in the body. Opioid analgesics are like the key that turns off the alarm, providing the necessary relief to help the person feel better and reduce stress on the body.

Nurses should administer the prescribed opioid analgesics promptly and monitor the patient's response to the medication. They should also assess for any side effects or adverse reactions and provide additional supportive care, such as hydration and emotional support.

• Ensure accurate dosage and timing of opioid administration as prescribed.
• Monitor the patient for effectiveness of pain relief and any potential side effects, such as respiratory depression or sedation.
• Maintain hydration to decrease blood viscosity and prevent further sickling of cells.
• Educate the patient and family about pain management strategies and the importance of medication adherence.
• Provide supportive care, including the use of warm compresses and comfortable positioning, to enhance overall comfort.

✘Incorrect answer options:

Applying a heating pad to the affected areas. While applying heat can help relieve some pain, it is not sufficient on its own to manage the severe pain experienced during a sickle cell crisis. Heat can be an adjunct therapy but not the primary intervention.

Encouraging Jean to walk around the unit. Ambulation might increase pain and stress during a sickle cell crisis due to the strain it places on already compromised tissues. Rest and relaxation are more appropriate during a crisis.

Providing Jean with ice packs for the affected areas. Cold therapy is generally not recommended during a sickle cell crisis because it can cause vasoconstriction, which may worsen the pain and exacerbate the crisis by further reducing blood flow.

EXPLANATION

✔Correct answer:

Capillary refill time of less than 3 seconds. Capillary refill time is a quick and effective measure of peripheral circulation. It assesses how well blood is perfusing to the extremities. By pressing on the nail bed until it turns white and then releasing, the time it takes for the color to return should be less than 3 seconds. This indicates adequate blood flow to the lower extremities, which is crucial for patients with sickle cell anemia who are at risk of vascular occlusions.

Sickle cell anemia leads to the formation of abnormally shaped red blood cells that can obstruct blood vessels, reducing blood flow and oxygen delivery to tissues. Monitoring capillary refill time helps in early detection of circulation issues, allowing for prompt intervention to prevent complications such as pain crises or tissue damage.

Imagine a garden hose that supplies water to a sprinkler. If the water flows freely and quickly when you turn on the tap, the sprinkler will work properly, ensuring the garden is well-watered. Similarly, quick capillary refill time indicates good blood flow to the extremities, ensuring tissues are well-perfused.

Nurses should regularly assess capillary refill time in patients with sickle cell anemia. Any delay in capillary refill time should be promptly reported and addressed to prevent further complications.

• Ensure the patient is well-hydrated to reduce blood viscosity and improve circulation.
• Administer prescribed medications such as pain relievers or hydroxyurea to manage pain and prevent sickle cell crises.
• Encourage movement and leg exercises to promote blood flow in the extremities.
• Monitor for signs of infection or other complications that may impair circulation.
• Educate the patient about recognizing early signs of circulation issues and when to seek medical attention.

✘Incorrect answer options:

Body temperature maintained at 99°F or lower. While maintaining a normal body temperature is important, it is not a specific measure of peripheral circulation. Fever management is crucial in sickle cell anemia due to the risk of infection, but it does not directly evaluate lower extremity circulation.

Ability to actively move toes through range of motion. This assesses motor function but not necessarily circulation. A patient might be able to move their toes even if circulation is compromised. It is an important assessment but not the most direct measure of circulation.

Sensation felt when touching the soles of the feet. Sensation tests the neurological function and is important in assessing for neuropathy, but it does not directly measure blood flow or circulation in the extremities.