A nurse is caring for a client during a follow up visit at a gastrointestinal clinic.

Exhibits

Which of the following interventions should the nurse implement?

Select all that apply.

Assess peripheral circulation hourly.

Assess the client's mouth every 8 hr.

Use humidification with oxygen therapy. Administer IV fluids.

Raise the knee position on the client's bed.

Use an automated blood pressure cuff on the client's arm. Prepare for platelet transfusion.

Answer and Explanation

Correct Answer : A,B,C

A. Assess peripheral circulation hourly. This is correct because clients with SCD are at risk of vaso-occlusive crisis, which can impair blood flow to the extremities and cause tissue ischemia and necrosis. The nurse should monitor for signs of poor circulation such as pallor, coolness, numbness, or pain.

B. Assess the client's mouth every 8 hr. This is correct because clients with SCD are prone to oral ulcers, infections, and dental problems due to chronic anemia and reduced oxygen delivery to the oral mucosa. The nurse should inspect the mouth for lesions, bleeding, inflammation, or infection and provide oral hygiene as needed.

C. Use humidification with oxygen therapy. Administer IV fluids. This is correct because clients with SCD need adequate hydration and oxygenation to prevent sickling of red blood cells and further complications. Humidification helps moisten the airways and prevent dehydration of the mucous membranes. IV fluids help maintain fluid and electrolyte balance and reduce blood viscosity.

D. Raise the knee position on the client's bed. This is incorrect because this can impede venous return and worsen peripheral circulation. The nurse should keep the client's extremities in a neutral position and avoid tight or restrictive clothing or devices.

E. Use an automated blood pressure cuff on the client's arm. Prepare for platelet transfusion. This is incorrect because this can cause mechanical trauma to the arm and trigger a vasoocclusive crisis. The nurse should use a manual blood pressure cuff and avoid applying pressure to the arm. Platelet transfusion is not indicated for clients with SCD unless they have thrombocytopenia or bleeding.

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Correct Answer is C

Explanation

- A. Incorrect. The nurse should educate the parent on the importance of nebulizer treatments to deliver medications that thin and loosen mucus in the airways.

- B. Incorrect. The nurse should advise the parent to contact the provider if the child has a fever, which could indicate an infection or inflammation in the lungs.

- C. Correct. The nurse should initiate a request for a high-frequency chest compression vest, which is a device that vibrates the chest wall and helps mobilize mucus from the lungs.

- D. Incorrect. The nurse should encourage the parent to support the child's participation in team sports, which can improve lung function and social skills.

A. Protective environment. B. Airborne. C. Contact. D. Droplet.

Correct Answer is D

Explanation

Choice A rationale:

Protective environment isolation precautions are used for immunocompromised patients to protect them from infections in the environment. It is not the appropriate precaution for a patient with bacterial meningitis, which is spread through respiratory droplets.

Choice B rationale:

Airborne precautions are used for diseases that are spread through the air and require a negative pressure room. Examples include tuberculosis and chickenpox. Bacterial meningitis is spread through respiratory droplets, not airborne transmission.

Choice C rationale:

Contact precautions are used for diseases that are spread by direct or indirect contact. Examples include MRSA and Clostridium difficile. Bacterial meningitis is primarily spread through respiratory droplets, not direct contact.

Choice D rationale:

Droplet precautions are used for diseases that are spread by respiratory droplets, such as influenza and bacterial meningitis. Patients with bacterial meningitis should be placed in a private room and wear a mask, and healthcare providers should wear a mask and eye protection when within 3 feet of the patient. This precaution helps prevent the spread of respiratory droplets containing the bacteria.

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A nurse is caring for a client during a follow up visit at a gastrointestinal clinic. Exhibits Which of the following interventions should the nurse implement? Select all that apply.

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A nurse is caring for a client during a follow up visit at a gastrointestinal clinic.

Exhibits

Which of the following interventions should the nurse implement?

Select all that apply.