A nurse is assisting with the plan of care for a patient who is experiencing sickle cell crises. What interventions should the nurse include in the plan of care?
Avoid administration of the influenza vaccine.
Provide a diet that is low in protein.
Decrease fluid intake to 1,500 mL daily.
Maintain the patient on bed rest.
The Correct Answer is D
Choice A rationale
Avoiding administration of the influenza vaccine is not a recommended intervention for a patient experiencing sickle cell crises. Vaccinations are important for patients with sickle cell disease to prevent infections that can trigger crises.
Choice B rationale
Providing a diet that is low in protein is not a recommended intervention for a patient experiencing sickle cell crises. Patients with sickle cell disease need a balanced diet that includes adequate protein to support tissue repair and growth.
Choice C rationale
Decreasing fluid intake to 1,500 mL daily is not a recommended intervention for a patient experiencing sickle cell crises. Adequate hydration is important to prevent sickling of cells and to maintain blood volume.
Choice D rationale
Maintaining the patient on bed rest is the correct intervention. Rest can help to decrease the body’s demand for oxygen, reduce stress on the body, and prevent complications such as acute chest syndrome.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Recommending consumption of cold items is a common intervention for managing stomatitis in clients receiving cancer treatment. Cold items can help to soothe the mouth and reduce pain. This is the correct choice.
Choice B rationale
Minimizing the use of gravies and sauces is not a standard intervention for managing stomatitis. While some clients may find these foods irritating, others may not.
Choice C rationale
Providing an alcohol-based mouthwash is not recommended for clients with stomatitis. Alcohol can dry out the mouth and exacerbate symptoms.
Choice D rationale
Discouraging drinking with a straw is not a standard intervention for managing stomatitis. Some clients may find that using a straw helps to bypass sore areas in the mouth.
Correct Answer is A
Explanation
Comparing the current blood pressure reading to the preoperative value is the first step the nurse should take. This will help determine if the patient’s blood pressure has significantly dropped, which could indicate hypovolemia or shock.
Choice B rationale
Covering the patient with a warm blanket may be helpful if the patient is feeling cold or showing signs of hypothermia, but it would not address the underlying cause of the low blood pressure.
Choice C rationale
Increasing the IV flow rate might be necessary if the patient is hypovolemic, but this decision should be based on additional assessment data and physician orders.
Choice D rationale
Reassuring the patient is important, but it should not be the first action. The nurse needs to assess and address the cause of the low blood pressure.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.