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.
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Related Questions
Correct Answer is B
Explanation
A. Diarrhea: While diarrhea can occur in some cases of ovarian cancer, it is not one of the most common manifestations.
B. Unexplained weight loss: Unexplained weight loss is a common symptom of ovarian cancer and may be due to factors such as cancer-related cachexia or decreased appetite.
C. Urinary retention: Urinary retention is not a typical manifestation of ovarian cancer. Urinary symptoms may occur if the cancer spreads to nearby structures, but urinary retention is not
common.
D. Abdominal bloating: Abdominal bloating is a common symptom of ovarian cancer, often accompanied by feelings of fullness and increased abdominal girth. It is often one of the earliest and most noticeable symptoms of the disease.
Correct Answer is D
Explanation
A. Hemoglobin A1C level is not typically assessed in patients with sickle cell anemia as it is primarily used to monitor long-term blood sugar control in individuals with diabetes mellitus.
B. While appetite may be relevant to the overall health of the patient, it is not the priority assessment in a patient with sickle cell anemia.
C. Reflexes may be assessed during the physical examination, but they are not the priority assessment in a patient with sickle cell anemia.
D. Vaccination history is the priority assessment in a patient with sickle cell anemia because individuals with sickle cell disease are at increased risk of infections, particularly from
encapsulated bacteria. Therefore, ensuring that the patient is up-to-date on vaccinations, including pneumococcal and meningococcal vaccines, is crucial for preventing serious infections.
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