A nurse is caring for an adolescent who is admitted with a vaso-occlusive crisis.
The nurse is planning care for the adolescent. Select the 5 interventions the nurse should include.
Instruct the parent to ensure the pneumococcal vaccine is current.
Give oral hydroxyurea.
Monitor oxygen saturation continuously.
Place the client on strict bed rest.
Apply cold compresses to the affected joints.
Administer meperidine IV for pain.
Correct Answer : A,B,C,D,H
A. Instruct the parent to ensure the pneumococcal vaccine is current.
This is a preventive measure to reduce the risk of infections in individuals with sickle cell disease.
B. Give oral hydroxyurea.
Hydroxyurea is used to decrease the frequency of pain episodes in sickle cell disease.
C. Monitor oxygen saturation continuously.
Continuous monitoring of oxygen saturation is important to detect any potential respiratory complications.
D. Place the client on strict bed rest.
Bed rest helps to reduce the metabolic demands on the body and promotes healing.
E. Restrict oral intake.
During a sickle cell crisis, it's generally not necessary to restrict oral intake unless there are specific indications to do so, such as severe abdominal pain or vomiting that prevents the child from tolerating oral feeds.
F. Apply cold compresses to the affected joints. Administer meperidine IV for pain.
Cold compresses may exacerbate vaso-occlusion, and meperidine is not the first-line choice for pain management in sickle cell crisis due to potential neurotoxicity.
G. Administer meperidine IV for pain.
Meperidine has a relatively short duration of action, which may necessitate frequent dosing. This can lead to more fluctuations in pain control.
H. Administer folic acid as prescribed.
Folic acid supplementation is often recommended for individuals with sickle cell disease to support red blood cell production.
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Related Questions
Correct Answer is D
Explanation
A. Teaching the client about ostomy care is unnecessary because surgical repair of Meckel diverticulum does not typically require an ostomy.
B. Administering total parenteral nutrition (TPN) is not routinely required postoperatively unless there are significant complications affecting digestion.
C. Initiating long-term antibiotic therapy is not standard post-surgical care for Meckel diverticulum repair; antibiotics are usually given short-term to prevent infection.
D. Maintaining an NG tube for decompression is appropriate because postoperative bowel rest is needed to prevent distension and reduce the risk of complications such as ileus.
Correct Answer is A
Explanation
A. A toddler's repeated refusal to let a nurse perform a routine medical assessment may indicate fear or discomfort around adults, which could be a potential indicator of child abuse or neglect.
B. A mother's hesitation to comfort her 6-month-old infant may be due to various reasons, such as cultural differences, lack of confidence, or personal preferences. It is not necessarily indicative of child abuse.
C. Bruises on a toddler's knees are a common finding in active children who are learning to walk and explore their environment. While bruises should always be assessed, they are not automatically indicative of child abuse.
D. An 8-month-old infant crying when a parent leaves the room is a normal separation anxiety response for an infant of this age and is not indicative of child abuse. This behavior is part of normal infant development.
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