a child newly diagnosed with sickle cell anemia sca is being discharged from the hospital which information is most important for the nurse to provide
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Nursing Elites

HESI RN

RN HESI Exit Exam Capstone

1. A child newly diagnosed with sickle cell anemia (SCA) is being discharged from the hospital. Which information is most important for the nurse to provide the parents prior to discharge?

Correct answer: D

Rationale: Proper hydration is crucial in managing sickle cell anemia (SCA) as it helps prevent sickling of red blood cells and reduces blood viscosity, which can lead to painful crises. Ensuring the child drinks enough fluids is essential to maintain adequate hydration levels and reduce the risk of complications. While nutritional guidelines and recognizing signs of infection are important aspects of care, maintaining proper hydration is the most immediate and critical factor in managing SCA and preventing crises.

2. A client was just taken off the ventilator after surgery and has a nasogastric tube draining bile-colored liquids. Which nursing measure will provide the most comfort to the client?

Correct answer: C

Rationale: Performing frequent oral care with a tooth sponge is the most appropriate nursing measure in this scenario. This helps maintain comfort and prevent dryness in clients with nasogastric tubes. Allowing the client to melt ice chips in the mouth may not address oral care needs effectively. Providing mints to freshen the breath is not the priority when the client needs oral care. Swabbing the mouth with glycerin swabs may not be as effective as performing thorough oral care with a tooth sponge.

3. Which of these findings should the nurse report immediately after a client has a liver biopsy?

Correct answer: D

Rationale: The correct answer is D, severe abdominal pain. After a liver biopsy, severe abdominal pain is a critical finding that requires immediate reporting as it may indicate internal bleeding or damage to the liver. The other vital signs provided in choices A, B, and C are within normal limits and may not be directly related to complications post liver biopsy. Therefore, the priority is to address the severe abdominal pain promptly to prevent any further complications.

4. A client receiving radiation therapy for breast cancer reports dry, peeling skin at the treatment site. What action should the nurse recommend?

Correct answer: B

Rationale: The correct recommendation for a client with dry, peeling skin at a radiation therapy treatment site is to use mild soap and water to cleanse the area. This approach helps in preventing skin irritation and reduces the risk of infection. Applying lotion (Choice A) may further irritate the skin due to the chemicals present in the lotion. Covering the area with a sterile dressing (Choice C) is not necessary unless there is an open wound that needs protection. Allowing the skin to air dry after washing (Choice D) may lead to further dryness and peeling.

5. Before a client with renal failure undergoes hemodialysis, what should the nurse assess?

Correct answer: A

Rationale: The correct answer is to check the client's potassium levels. Potassium levels are crucial to assess before hemodialysis in a client with renal failure because hyperkalemia (high potassium) is a common complication in these patients. Hemodialysis aims to remove excess potassium from the blood, making it essential to monitor potassium levels to determine the need for appropriate interventions. Reviewing the client's medication list (Choice B) is important for overall care but is not as directly relevant to the immediate concerns before hemodialysis. Assessing peripheral pulses (Choice C) and monitoring urine output (Choice D) are important aspects of nursing assessment but are not as directly related to the specific preparation needed before hemodialysis in a client with renal failure.

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