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 B
Explanation
Rationale:
A. Cheyne-Stokes respirations: This irregular breathing pattern is common in clients nearing end of life due to neurologic decline. It is not a direct indicator of pain and does not necessarily require pain medication unless associated with distress.
B. Restlessness: Restlessness in a palliative care client often signals unrelieved pain, discomfort, or anxiety. It is a nonverbal cue frequently observed in clients unable to communicate pain and should prompt consideration of analgesia.
C. Mottled skin: Mottling is a sign of reduced perfusion and impending death. It reflects circulatory changes but does not directly indicate pain or warrant pain medication unless accompanied by other signs of distress.
D. Constricted pupils: Pupil constriction may result from certain medications (e.g., opioids) or brainstem pressure but is not a reliable sign of pain. It does not, by itself, indicate a need for analgesic intervention.
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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