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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Dark brown blood noted in emesis is a concerning finding and may indicate active bleeding. This requires immediate intervention by the nurse, as post-tonsillectomy hemorrhage is a potential complication.
B. An axillary temperature of 38° C (100° F) is slightly elevated, but it is not the most concerning finding in this situation. It may be expected after surgery due to inflammation and the body's stress response.
C. A pain level of 5 on the FACES scale indicates moderate pain. While pain management is important, it is not the most urgent concern in this situation.
D. Frequent swallowing may be expected after a tonsillectomy due to postoperative
throat discomfort. It is important to monitor for bleeding, but dark brown blood in emesis is a more immediate concern.
Correct Answer is D
Explanation
A. Tremors are not a typical clinical manifestation of heart failure. They may be associated with conditions like hyperthyroidism or certain medications.
B. Bradycardia (slow heart rate) is not a typical finding in heart failure. In fact, tachycardia (fast heart rate) is more commonly associated with this condition.
C. Increased appetite is not a typical clinical manifestation of heart failure. Children with heart failure may actually experience poor appetite due to decreased cardiac output.
D. Correct. Tachypnea (rapid breathing) is a common clinical manifestation of heart
failure. It can occur as the body tries to compensate for the decreased cardiac output by increasing respiratory rate in an effort to maintain oxygenation.
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