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. Change the drainage tubing every 48 hr: Closed wound drainage systems are designed to remain intact and sterile until removal. Routine replacement of tubing can introduce pathogens and is not recommended unless there is evidence of damage or contamination.
B. Observe for drainage flow through the tubing: Monitoring the flow and character of drainage ensures the system is functioning correctly and allows early detection of complications like blockage, dislodgment, or infection.
C. Remove the drain if output from the drain increases: An increase in drainage volume can signal active bleeding, infection, or poor wound healing. Instead of removing the drain, the nurse should notify the provider for further evaluation and guidance on next steps.
D. Irrigate the drain to maintain suction: Closed drainage systems like Jackson-Pratt or Hemovac are designed to maintain negative pressure without irrigation. Introducing fluid into the system can break the vacuum seal, reduce effectiveness, and increase the risk of infection.
Correct Answer is B
Explanation
Rationale:
A. Butorphanol tartrate: This opioid analgesic can cause respiratory depression in the newborn if given too close to delivery. At 10 cm dilation and during pushing, it's generally too late to administer systemic opioids safely.
B. Pudendal block: A pudendal block provides localized perineal anesthesia and is safe for use during the second stage of labor when the client is fully dilated and pushing. It effectively reduces pain from stretching and pressure without affecting uterine contractions or fetal status.
C. Naloxone hydrochloride: Naloxone is not a pain-management measure; it is an opioid antagonist used to reverse opioid-induced respiratory depression. It does not provide analgesia and is not administered for pain relief during labor.
D. Spinal anesthesia: Spinal anesthesia is typically administered prior to a planned cesarean birth or late in the first stage of labor. It is not appropriate once the client is fully dilated and actively pushing, as it could delay delivery and complicate maternal positioning.
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