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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Radiation exposure: Radiation exposure can cause aplastic anemia, but if the cause is unknown, it is less likely to be due to a specific and identifiable event like radiation exposure.
B. An autoimmune disorder: When the cause of aplastic anemia cannot be diagnosed, it is often attributed to an autoimmune disorder where the body attacks its own bone marrow cells.
C. Chemotherapy drugs: Chemotherapy drugs can cause aplastic anemia, but this cause would typically be known based on the patient's medical history.
D. Toxins: Toxins can cause aplastic anemia, but like chemotherapy drugs and radiation, this cause would generally be identifiable.
Correct Answer is A
Explanation
A. The activity of the bone marrow is depressed. Aplastic anemia is a condition where the bone marrow fails to produce sufficient numbers of blood cells, including red cells, white cells, and platelets.
B. Red cells are absent as a result of chronic blood loss. This describes a condition like iron- deficiency anemia, not aplastic anemia.
C. The bone marrow fails to produce lymphocytes. Aplastic anemia affects the production of all blood cells, not just lymphocytes.
D. The kidneys fail to produce red blood cells. This describes anemia of chronic kidney disease, not aplastic anemia. In aplastic anemia, the problem lies with the bone marrow, not the kidneys.
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