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| NUR 211 EXAM
A nurse is caring for a client who has streptococcal pneumonia and a prescription
for penicillin G by intermittent IV bolus. 10 minutes into the infusion of the third
dose, the client reports that the IV site itches and that he feels dizzy and short of
breath. Which of the following actions should the nurse take first?
Stop the infusion.
Call the client's provider.
Elevate the head of the bed
,Auscultate the client's breath sounds. - ANSWER-Stop the infusion
Rationale: When using the airway, breathing, circulation approach to client care,
the nurse should place the priority on stopping the infusion. The client is exhibiting
signs of penicillin anaphylaxis and the first action that should be taken is to
withdraw the medication.
Rationale: The nurse should auscultate the client's breath sounds; however, another
action is the priority. Rationale: The nurse should elevate the head of the bed;
however, another action is the priority. Rationale: The nurse should call the client's
provider; however, another action is the priority.
What drug is used for the maintenance of sickle cell disease?
Hydroxyurea
hydroxychloroquine
Hydromorphone - ANSWER-Hydroxyurea
Rationale: Hydroxyurea is used in the treatment of sickle cell disease.
Rationale: Hydroxychloroquine is used in the treatment of Lupus.
Rationale: Hydromorphone is used for pain management
What are some adverse effect of Hydroxyurea? - ANSWER-Suppression of RBC,
WBC, and Platelets.
Bone marrow suppression
, What are some triggers for sickle cell crisis? - ANSWER-Dehydration, fever,
stress, cold temperatures, illness, extreme exercise, infection, hypoxia, alcohol,
tobacco use, pregnancy. Sometimes there are no triggers.
What would a focused assessment look like for someone who is in a SCD crisis? -
ANSWER-Respiratory assessment, check oral mucosa, level of consciousness,
capillary refill, skin color/turgor, general appearance, pulses, monitor for shock,
V.S., pain, visual acuity, extremities (examine for clots), psychosocial, monitor for
signs and symptoms of stroke
Upon arrival to the unit follow a SCD exacerbation, what is a priority nursing
intervention? - ANSWER-Hydration - IV fluids to help those sickle cells return to
normal shape. (think about fluffing a pillow)
Oxygen
Pain management
Support
A nurse in a providers office is talking with a client about risk factors for
osteoporosis. Which of the following factors should the nurse include? (select all
that apply)
Aging
Caffeine intake
Secondhand smoke
Obesity