A nurse in an emergency department is caring for a client who is in a sickle cell crisis. Which of the following actions should the nurse take?(Select all that apply.).
Administer oxygen.
Administer opioids.
Administer whole blood.
Elevate the head of the bed to 30°.
Keep the client NPO.
Correct Answer : A,B,D
Choice A rationale:
The nurse should administer oxygen to the client experiencing a sickle cell crisis. Sickle cell crisis can cause vaso-occlusion, leading to tissue hypoxia and pain. Administering oxygen helps to improve tissue oxygenation and relieve symptoms.
Choice B rationale:
Administering opioids is appropriate for managing the severe pain associated with a sickle cell crisis. Opioids are effective analgesics that can help alleviate the acute pain experienced by the client.
Choice C rationale:
Administering whole blood is not typically indicated for a sickle cell crisis. Whole blood transfusion is reserved for specific indications, such as severe anemia or acute blood loss, but it is not a standard treatment for sickle cell crisis pain.
Choice D rationale:
Elevating the head of the bed to 30° can improve oxygenation and reduce the workload on the respiratory system, which is beneficial for clients experiencing a sickle cell crisis. It helps to optimize lung expansion and alleviate hypoxia.
Choice E rationale:
Keeping the client NPO (nothing by mouth) is not necessary in a sickle cell crisis. There is no indication that the client cannot tolerate oral intake, so allowing them to eat and drink as usual is appropriate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Wearing gloves when changing the cat's litter box is essential during chemotherapy because some chemotherapy drugs can be excreted in bodily fluids, including feces. Protecting against direct contact with potentially harmful substances is crucial to minimize exposure risks.
Choice B rationale:
Taking the temperature once each week is not a relevant precaution during chemotherapy. Monitoring temperature is important, but it should be done more frequently, such as daily, as chemotherapy can cause immunosuppression, increasing the risk of infection.
Choice C rationale:
Being able to attend a concert is not related to precautions during chemotherapy. It is essential for clients undergoing chemotherapy to avoid large gatherings and events where they might be exposed to infections.
Choice D rationale:
Allowing the toothbrush to dry completely between each use is a good hygiene practice but not specifically related to chemotherapy precautions. Proper oral hygiene is essential during chemotherapy, but using a soft toothbrush and regularly replacing it are more relevant considerations.
Correct Answer is A
Explanation
The client's daily peak expiratory flow (PEF) measures 85% above personal best.
Choice A rationale:
Salmeterol is a long-acting beta-agonist used to treat asthma. Improvement in the client's daily peak expiratory flow (PEF) of 85% above their personal best indicates effective bronchodilation and better asthma control.
Choice B rationale:
ABGs showing a pH level of 7.32 are not indicative of the effectiveness of salmeterol. ABG values assess the client's acid-base balance and gas exchange, but they do not directly reflect the action of the medication.
Choice C rationale:
A decrease in forced expiratory volume after treatment with medication indicates a lack of response to the therapy, not an effective outcome. It suggests the medication is not adequately controlling the client's asthma symptoms.
Choice D rationale:
Wheezing limited to expiration is not a clear indicator of medication effectiveness. Wheezing can be present in various respiratory conditions and is not solely associated with asthma control. Exhibit. The correct answer is choice B: Increase the rate of the infusion by 160 units/hr.
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