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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
A rectal body temperature of 37.3 C (99.1 F) in a school-age child is within the normal range, so it does not need to be reported.
Choice B rationale
A heart rate of 68/min in an 18-month-old toddler is below the normal range (80-130 beats per minute). This could indicate a serious condition such as heart block or hypothermia and should be reported to the provider.
Choice C rationale
A blood pressure of 132/82 mm Hg in an adolescent is slightly elevated but within acceptable limits for a teenager, especially if the teenager was nervous or anxious during the measurement.
Choice D rationale
A respiratory rate of 36/min in a 3-month-old infant is within the normal range (30-60 breaths per minute), so it does not need to be reported.
Correct Answer is ["A","C","E"]
Explanation
Choice A rationale
Providing a high-calorie diet is a recommended action for a child who has received partial-thickness burns to
over 50% of his body. After a burn injury, the body needs extra calories and protein to heal, fight infection, and maintain its functions. A high-calorie diet can help meet these increased nutritional needs.
Choice B rationale
Administering analgesics intramuscularly (IM) is not a recommended action for a child with partial- thickness burns. Pain management is crucial in burn care, but analgesics should be given orally or intravenously, not IM, to avoid additional pain and tissue damage.
Choice C rationale
Monitoring intake and output is a recommended action for a child who has received partial-thickness burns to over 50% of his body. This can help assess the child’s hydration status, kidney function, and response to fluid replacement therapy.
Choice D rationale
Removing splints during sleep is not a recommended action for a child with partial-thickness burns. Splints are used to prevent contractures by keeping the joints in a functional position. They should be worn as prescribed by the healthcare provider, which often includes during sleep.
Choice E rationale
Changing dressings using aseptic technique is a recommended action for a child who has received partial- thickness burns to over 50% of his body. This can help prevent infection, promote healing, and assess the burn’s progress.
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