A nurse is caring for a client during a follow up visit at a gastrointestinal clinic.
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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D","E"]
Explanation
A. Firmly massaging the uterine fundus helps promote uterine contraction and reduce postpartum hemorrhage.
B. Providing emotional support helps address the client’s anxiety and distress.
C. Administering oxygen supports tissue perfusion, especially as the client is showing signs of hypovolemic shock.
D. Weighing perineal pads helps quantify blood loss and assess the severity of hemorrhage.
E. Inserting an indwelling urinary catheter ensures accurate output measurement and prevents bladder distension, which can interfere with uterine contraction.
Correct Answer is D
Explanation
Choice A rationale:
Placing the client on airborne precautions for measles is the appropriate action. Measles is highly contagious and spreads through respiratory droplets. Airborne precautions, including wearing a mask, are essential to prevent the transmission of the virus to others. This action is in line with infection control protocols and ensures the safety of both healthcare providers and other patients.
Choice B rationale:
Having the client wear a mask for transport to radiology is a necessary precaution to prevent the spread of measles to others in the healthcare facility. It helps contain respiratory droplets and reduces the risk of transmission. This action aligns with infection control guidelines and is appropriate in this context.
Choice C rationale:
Wearing an N95 respirator when caring for a client with measles is necessary to protect healthcare providers from inhaling infectious particles. Measles is highly contagious, and airborne precautions, including the use of appropriate respiratory protection, are crucial. This action demonstrates the nurse's understanding of infection control measures.
Choice D rationale:
Ensuring the client's room maintains a positive airflow is wrong in anairborne infection isolation room. Negativeairflow helps prevent the contaminated air from flowing out of the room and spreading the infection to other areas of the healthcare facility. This action is consistent with the recommended infection control practices for airborne diseases.
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