A 16-year-old is admitted with sickle cell crisis. The patient has a pain scale rating of 10 and the following vital signs: HR 115, BP 120/82, RR 18, oxygen saturation 91%, temperature 101.4°F. Select all the appropriate nursing interventions for this patient at this time?
Remove restrictive clothing or objects from the patient
Administer IV Morphine per MD order
Administer oxygen per MD order
Place on NPO
Start intravenous fluids per MD order
Keep patient on bed rest
Correct Answer : A,B,C,D,E,F
A. Remove restrictive clothing or objects from the patient: This helps to promote comfort and improve circulation.
B. Administer IV Morphine per MD order: Morphine is a common medication used to manage severe pain associated with sickle cell crisis.
C. Administer oxygen per MD order: Oxygen may be needed to improve oxygen saturation and support respiratory function, especially if the patient is hypoxic.
D. Place on NPO: This is appropriate in case the patient needs any procedures or interventions that require fasting.
E. Start intravenous fluids per MD order: Intravenous fluids help to hydrate the patient and improve blood flow, which can help alleviate symptoms of sickle cell crisis.
F. Keep patient on bed rest: Bed rest is important to conserve energy and minimize the risk of further complications during a sickle cell crisis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Cystocele: A cystocele occurs when the bladder bulges into the vaginal canal, which can cause symptoms such as dyspareunia, backache, pelvic pressure, urinary tract infections, and urinary urgency.
B. Fibroid: Fibroids are benign tumors of the uterus and can cause pelvic pain and pressure, but they are not typically associated with urinary symptoms.
C. Ovarian cyst: Ovarian cysts can cause pelvic pain and pressure but are not usually associated with urinary symptoms like urinary urgency.
D. Rectocele: A rectocele occurs when the rectum bulges into the vaginal canal, which can cause symptoms like dyspareunia and pelvic pressure, but it is more likely to cause constipation than urinary urgency.
Correct Answer is A
Explanation
A. Performing breast self-examination (BSE) on the first day of each month provides a consistent schedule for the client to conduct the examination, making it easier to remember and ensuring regularity.
B. The first day of the menstrual cycle may not be the best time to perform BSE for all women, as breast tissue may be more tender or swollen during menstruation.
C. Seven days after the menstrual cycle begins may not be the best time for BSE, as hormonal fluctuations and breast changes may not yet have stabilized.
D. Performing BSE every month during ovulation is not necessary, as ovulation does not directly affect breast tissue changes that need to be monitored.
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