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. Hemophilia A: Hemophilia A is caused by a deficiency of factor VIII, leading to problems with blood clotting.
B. Hemophilia B: Hemophilia B is caused by a deficiency of factor IX, not factor VIII.
C. Christmas disease: Christmas disease is another name for Hemophilia B, which is caused by a deficiency of factor IX.
D. Sickle cell disease: Sickle cell disease is a genetic disorder affecting hemoglobin, not a clotting factor deficiency.
Correct Answer is A
Explanation
A. Three to seven days after menses stops. This is the best time to perform BSE as the breasts are least likely to be swollen and tender during this period.
B. Prior to the beginning of menses. Breasts are more likely to be swollen and tender before menstruation, which can make it harder to detect abnormalities.
C. On the second day of menstruation. During menstruation, hormonal changes can affect breast tissue, making the examination less reliable.
D. On the same day every month. For those with regular menstrual cycles, it is recommended to perform BSE a few days after menses stops for more accurate results.
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