It is important to keep the client in sickle cell crisis hydrated to prevent further sickling of the blood. Option A: Taking hourly blood pressures with mechanical cuff is incorrect because a mechanical cuff places too much pressure on the arm. Option C: Position in high Fowler’s with knee gatch raised is inappropriate because it impedes circulation. Option D: Administering Tylenol is too mild an analgesic for the client in crisis.
The normal platelet count is 120,000–400, Bleeding occurs in clients with low platelets. The priority is to prevent and minimize bleeding. Options B and D are of lesser priority and are incorrect in this instance. Option C is important, but platelets do not carry oxygen.
The peak incidence of ALL is at 4 years (range 3-10). It is uncommon after the mid-teen years. The peak incidence of chronic myelogenous leukemia (CML) is 45-55 years. The peak incidence of acute myelogenous leukemia (AML) occurs at 60 years. Two-thirds of cases of chronic lymphocytic leukemia (CLL) occur after 60 years.
Hydration is important in the client with sickle cell disease to prevent thrombus formation. Popsicles, gelatin, juice, and pudding have high fluid content. Options A, B, and D do not aid in hydration and are, therefore, incorrect.
A history of cerebral hemorrhage is a contraindication to tPA because it may increase the risk of bleeding. TPA acts by dissolving the clot blocking the coronary artery and works best when administered within 6 hours of onset of symptoms. Option C: Prior MI is not a contraindication to tPA. Option D: Patients receiving tPA should be observed for changes in blood pressure, as tPA may cause hypotension.
Clients with autoimmune thrombocytopenic purpura (ATP) have low platelet counts, making answer A the correct answer. Options B, C, and D: White cell counts, potassium levels, and PTT are not affected in ATP.
Radiation therapy often causes sterility in male clients and would be of primary importance to this client. The psychosocial needs of the client are important to address in light of the age and life choices. Hodgkin’s disease, however, has a good prognosis when diagnosed early. Answers B, C, and D are incorrect because they are of lesser priority.
Taking a trip to the museum is the only answer that does not pose a threat. Options A, B, and C: A family vacation in the Rocky Mountains at high altitudes, cold temperatures, and airplane travel can cause sickling episodes and should be avoided.
Normal hemoglobin values range from 11.5-15.0. This vegetarian patient is mildly anemic. When food is prepared in iron cookware its iron content is increased. Option A: In addition, dark green leafy vegetables, such as spinach and kale, and legumes are high in iron. Option B: Mild anemia does not require that animal sources of iron be added to the diet. Many non-animal sources are available. Option D: Coffee and tea increase gastrointestinal activity and inhibit absorption of iron.
Identify the values of the department will set the guiding principles within which the department will operate its activities
Structure standards include management system, facilities, equipment, materials needed to deliver care to patients. Rotation of duty is a management system.
Process standards include care plans, nursing procedure to be done to address the needs of the patients.
This is a step in a quality control process and not a basic step in the control process.
Criteria are specific characteristics used to measure the standard of care.
Instructing the members involves a directing function.
This refers to an outcome standard, which is a result of the care that is rendered to the patient.
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NCLEX-RN Test #20
