answers
A nurse educator is teaching a group of patients about prevention of sickle cell
crises. What should the nurse instruct about the precipitating factors that could
contribute to a sickle cell crisis? Select all that apply.
1. Increased fluid intake
2. Altitude
3. Fever
4. Vomiting
5. Regular exercise Ans✓✓✓ 2,3,4:
1. This is incorrect. Regular exercise and increased fluid intake are recommended
activities that will not contribute to a sickle cell crisis.
2. This is correct. Fever, vomiting, and altitude are some of the precipitating
factors that contribute to a sickle cell crisis.
3. This is correct. Fever, vomiting, and altitude are some of the precipitating
factors that contribute to a sickle cell crisis.
4. This is correct. Fever, vomiting, and altitude are some of the precipitating
factors that contribute to a sickle cell crisis.
5. This is incorrect. Regular exercise and increased fluid intake are recommended
activities that will not contribute to a sickle cell crisis.
A nurse is assessing a patient in the ED with the complaint of sudden onset of
severe back pain, tachycardia, and hypotension. Which interventions should the
nurse anticipate? (select all that apply)
a. Electrocardiogram
b. Aortic arteriography
c. Ultrasonography
,d. Chest x-ray
e. Computed tomography scan Ans✓✓✓ a,c,e
A nurse is assessing a patient in the emergency department with the complaint of
sudden onset of severe back pain, tachycardia, and hypotension. Which
interventions should the nurse anticipate? (Select all that apply.)
a. Electrocardiogram
b. Aortic arteriography
c. Ultrasonography
d. Chest x-ray
e. Computed tomography scan Ans✓✓✓ a,c,e Explanation: Ultrasonography can
be done quickly and efficiently at the bedside to rule out aortic dissection. CT scan
may also be done to definitively diagnose or rule out aortic dissection. An ECG is
necessary to rule out MI. Aortic arteriography is a highly invasive and lengthy
procedure at a time when quick and uncomplicated is essential. CXR cannot
provide a definitive diagnosis of aortic dissection.
A nurse is caring for a patient who has undergone a flexible bronchoscopy for
evaluation of a laryngeal tumor. Which of the following symptoms, if noted,
should be reported immediately to the provider?
a. Blood-tinged sputum
b. Hematuria
c. Hacking cough
d. Wheezing Ans✓✓✓ d. Explanation: Wheezing indicated narrowing of the
airways which could result in hypoxia.
,A nurse is performing the immediate postoperative assessment of a patient who
has just undergone CEA. What is the most important assessment to be reported
immediately?
a. A complaint of 7/10 pain
b. Falling back to sleep after assessment
c. An asymmetric smile
d. Complaint of a sore throat Ans✓✓✓ c.
A nurse is performing the immediate postoperative assessment of a patient who
just underwent CEA. What is the most important assessment to be reported
immediately?
a. A complaint of 7/10 pain
b. Falling back to sleep after assessment
c. An asymmetric smile
d. Complaint of a sore throat Ans✓✓✓ c. Explanation: An asymmetric smile may
indicate damage to cranial nerve seven—the physician should be made aware
immediately. Sleepiness is normal postanesthesia, a sore throat is not unusual
post-intubation, and pain should be treated after notifying the physician about
the asymmetric smile.
A nurse is planning care for a patient with sickle cell disease. The nurse should
contact the provider about which prescribed intervention?
1. Administer ordered analgesic medications around the clock
2. Place patient in position of comfort
3. Use heat or cold packs as tolerated
4. Support the patient's joints and extremities with pillows Ans✓✓✓ 3 :
, 1. The patient with sickle cell disease who is in a sickle cell crisis will likely have
extreme pain. To aid in caring for this patient, the nurse will administer ordered
analgesic medications around the clock, place the patient in a position of comfort,
and support the patient's joints and extremities with pillows.
2. The patient with sickle cell disease who is in a sickle cell crisis will likely have
extreme pain. To aid in caring for this patient, the nurse will administer ordered
analgesic medications around the clock, place the patient in a position of comfort,
and support the patient's joints and extremities with pillows.
3. The use of heat or cold packs is contraindicated in the sickle cell patient.
Ischemic tissue is fragile and has reduced sensation, increasing the risk of burn
injury from hot compresses, whereas cold compresses promote sickling.
4. The patient with sickle cell disease who is in a sickle cell crisis will likely have
extreme pain. To aid in caring for this patient, the nurse will administer ordered
analgesic medications around the clock, place the patient in a position of comfort,
and support the patient's joints and extremities with pillows.
A nurse is providing care for a patient newly diagnosed with heart disease. Which
dietary, activity, or lifestyle modification(s) should be included in the plan of care?
(select all that apply)
a. Stop smoking
b. Drink lots of water
c. Limit sedentary lifestyle
d. Eat a diet rich red meat protein
e. Limit alcohol Ans✓✓✓ a,c,e Explanation: Smoking, exercise, and alcohol intake
are modifiable risk factors for heart disease. Patients should not be told to drink
lots of water as the heart may not be able to handle excessive fluids. A diet rich in
red meat is a risk factor