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
Apply warm compresses to the affected areas.
Decrease the child's fluid intake.
Administer furosemide IV twice per day.
Initiate contact precautions.
The Correct Answer is A
A. Applying warm compresses can help to improve blood flow and relieve pain in areas affected by a sickle cell crisis. This is a beneficial intervention.
B. Decreasing fluid intake is not recommended. Maintaining hydration is important in the management of sickle cell disease, as it helps to prevent dehydration and reduces the risk of sickling.
C. Furosemide is a diuretic and is not typically used in the treatment of a sickle cell crisis.
It is not an appropriate intervention in this situation.
D. Contact precautions are not necessary for a sickle cell crisis. This crisis is not a contagious condition. Standard precautions for infection control should be followed.
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Related Questions
Correct Answer is C
Explanation
A. Jacket restraints are typically used to secure a child's arms during procedures. They are not specifically designed for venipuncture in infants.
B. Elbow restraints are used to secure the child's elbows, often during procedures involving the upper body. They are not typically used for venipuncture.
C. The mummy restraint is specifically designed to secure an infant's arms during venipuncture. It wraps the arms snugly, allowing access to the veins while minimizing movement.
D. Mitten restraints are used to prevent the child from manipulating equipment or accessing areas that should be restricted. They are not designed for venipuncture procedures.
Correct Answer is D
Explanation
A. Negative doll's eye reflex (also known as oculocephalic reflex) is a normal finding in infants. It is a reflexive movement of the eyes in the opposite direction of the head
movement.
B. A sunken anterior fontanel can indicate dehydration, which is a concern. However, in a 2-month-old with heart failure, a high heart rate (tachycardia) may indicate worsening of the heart failure and needs to be addressed promptly.
C. A potassium level of 5.1 mEq/L is within the normal range for infants. While electrolyte balance is important, it is not the priority in this situation.
D. This is the correct answer. A heart rate of 162/min in a 2-month-old infant with heart failure is elevated and requires immediate attention. It may indicate worsening heart
failure or an adverse reaction to the medication (furosemide) being administered. The nurse should assess the infant's condition, notify the healthcare provider, and intervene as necessary.
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