A nurse is caring for an adolescent who has sickle-cell anemia. Which of the following manifestations indicates acute chest syndrome and should be immediately reported to the provider?
Hematuria
Sneezing
Substernal retractions
Temperature 37.9° C (100.2° F)
The Correct Answer is C
Rationale:
A. Hematuria: Blood in the urine can occur with sickle cell disease due to renal papillary necrosis, but it is not specific to acute chest syndrome and does not require immediate emergency action in this context.
B. Sneezing: Sneezing is typically associated with upper respiratory infections or allergies and is not indicative of acute chest syndrome. It is not a critical symptom in this scenario.
C. Substernal retractions: Substernal retractions are a sign of respiratory distress and can indicate acute chest syndrome a life-threatening complication of sickle cell anemia. It involves pulmonary infiltration and can rapidly progress to hypoxia and respiratory failure, requiring urgent intervention.
D. Temperature 37.9° C (100.2° F): While fever in a sickle cell client should be closely monitored and reported, this temperature is low-grade. Alone, it does not immediately signal acute chest syndrome without accompanying respiratory symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Auscultation: This step is performed after inspection and before percussion or palpation to avoid altering bowel sounds. It allows the nurse to assess for the presence, frequency, and character of bowel sounds without stimulating them artificially.
B. Inspection: This is the first step in the abdominal assessment. It involves visually examining the abdomen for contour, symmetry, skin changes, pulsations, or visible masses without touching the patient, helping establish a baseline.
C. Palpation: Palpation is the final step in abdominal assessment to prevent interference with bowel sounds. It allows the nurse to detect tenderness, masses, or organ enlargement, but should only be done after auscultation and percussion.
D. Percussion: This is done after auscultation and provides information on underlying structures, such as gas, fluid, or masses. It helps differentiate between dullness, resonance, or tympany across abdominal quadrants.
Correct Answer is ["200"]
Explanation
Calculation:
Total volume = 100 mL.
- Convert the infusion time from minutes to hours.
Infusion time = 30 min / 60 min/hr
= 0.5 hr.
- Calculate the infusion rate in milliliters per hour (mL/hr).
Infusion rate (mL/hr) = Total volume (mL) / Infusion time (hr)
= 100 mL / 0.5 hr
= 200 mL/hr.
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