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. "My doctor will perform pelvic exams to detect for ovarian cancer.": Pelvic exams can help detect ovarian cancer or abnormalities in the pelvic region, although they are not always definitive.
B. "I will develop ovarian cancer If I have the BRCA1 gene.": While having the BRCA1 gene mutation increases the risk of ovarian cancer, not everyone with this gene mutation will develop the disease.
C. "I will have regular Pap tests to monitor for ovarian cancer.": Pap tests are used to screen for cervical cancer, not ovarian cancer.
D. "A decreased CA125 level places me at greater risk for ovarian cancer.": An elevated CA125 level is associated with ovarian cancer, not a decreased level.
Correct Answer is A
Explanation
A. "You will need to empty your bladder just before the exam.": Emptying the bladder before a pelvic examination allows for better visualization and manipulation of the pelvic organs.
B. "You should douche the evening prior to the examination.": Douching is not recommended before a Pap test as it can disrupt the natural flora of the vagina and may interfere with test results.
C. "You will be required to sign an informed consent prior to the exam.": Informed consent may be required for certain procedures but is not typically needed for a Pap test.
D. "You will be given light sedation before the examination starts.": Sedation is not typically used for a Pap test, which is a simple procedure that does not usually cause significant discomfort.
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