A nurse is caring for a school- age child who is experiencing a sickle cell crisis.
Which of the following actions should the nurse take?
initiate contact precaution
Apply warm compresses to the affected area.
Decrease the child's fluid intake.
Administer furosemide IV twice per day.
The Correct Answer is B
Choice A rationale
Initiating contact precautions is not necessary for a child experiencing a sickle cell crisis. Sickle cell disease is not contagious and does not require isolation precautions.
Choice B rationale
Applying warm compresses to the affected area can help increase blood flow and reduce pain during a sickle cell crisis. Warmth can help dilate blood vessels, allowing more blood to reach the affected area and reducing the blockage caused by the sickle cells.
Choice C rationale
Decreasing the child’s fluid intake is not recommended during a sickle cell crisis. In fact, it’s important to encourage fluid intake to prevent dehydration, which can worsen the crisis.
Choice D rationale
Administering furosemide IV twice per day is not typically part of the treatment plan for a sickle cell crisis. Furosemide is a diuretic, which could potentially lead to dehydration, worsening the crisis.
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Related Questions
Correct Answer is B
Explanation
When prioritizing care for multiple clients, the nurse should first assess the client who is most unstable and has the most urgent needs. In this case, the adolescent with sickle cell anemia and slurred speech should be assessed first. Slurred speech could indicate a stroke, which is a life-threatening condition that requires immediate medical attention. The other clients, while they also require care, are not in immediate danger and can be assessed after the adolescent with sickle cell anemia.
Correct Answer is C
Explanation
The correct answer is C.
Choice A reason: A White Blood Cell (WBC) count of 20,000/mm³ is significantly higher than the normal range for children, which is typically between 5,000 to 10,000/mm³. In the context of acute lymphoblastic leukemia (ALL), a high WBC count could indicate an active disease process or a reaction to treatment, rather than a therapeutic effect.
Choice B reason: A hemoglobin level of 5.5 g/dL is quite low, as the normal range for children is generally between 11 to 16 g/dL. This level of hemoglobin suggests anemia, which is a common condition in patients with leukemia due to the disease itself or as a side effect of chemotherapy. It does not necessarily indicate that the treatment is having a therapeutic effect.
Choice C reason: A Platelet count of 150,000/mm³ is within the lower end of the normal range for children, which is approximately 150,000 to 450,000/mm³. This can be considered a sign that the treatment is working effectively, as it indicates bone marrow recovery and the production of platelets is returning to normal levels.
Choice D reason: A Red Blood Cell (RBC) count of 3/mm³ is extremely low. The normal range for children’s RBC count is about 4 million to 5.5 million/mm³. Such a low RBC count would indicate severe anemia and is not a sign of effective treatment for ALL.
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