A nurse is caring for an adolescent who is experiencing an acute sickle cell crisis. Which of the following actions should the nurse take?
Prepare to administer a potassium IV bolus.
Provide hydration orally and IV.
Request a prescription for meperidine.
Administer multiple units of platelets.
The Correct Answer is B
Choice A reason: Preparing to administer a potassium IV bolus is not typically indicated in sickle cell crisis unless there is a documented potassium deficiency. Potassium levels must be carefully monitored to avoid hyperkalemia.
Choice B reason: Providing hydration both orally and intravenously is crucial in managing sickle cell crisis. Hydration helps to reduce blood viscosity and improve circulation, which can alleviate the pain and prevent further sickling of red blood cells.
Choice C reason: Requesting a prescription for meperidine is not recommended for pain management in sickle cell crisis due to the risk of seizures and other side effects. Other pain medications, such as morphine, are preferred.
Choice D reason: Administering multiple units of platelets is not a standard treatment for sickle cell crisis. Platelet transfusion is typically reserved for patients with thrombocytopenia or active bleeding, not for sickle cell crisis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Irregular bluish pigmentation on the sacral area could indicate a Mongolian spot, which is common and usually harmless, but it could also suggest other conditions that may require further evaluation. Reporting this finding is important for proper assessment and documentation.
Choice B reason: Slow, rhythmic movements of the lower extremities are normal in newborns and are known as primitive reflexes. These movements are expected and do not typically require reporting unless they are absent or abnormal.
Choice C reason: An anterior fontanel size of 3 cm (1.2 in) is within the normal range for a newborn. The fontanel should be soft and flat, and changes in size or tension should be monitored over time.
Choice D reason: Enlarged breasts in newborns are also common due to maternal hormones and usually resolve without intervention. It is not a finding that typically requires immediate reporting unless there is redness, swelling, or discharge.
Correct Answer is A
Explanation
Choice A reason: A gluten-free diet is essential for managing celiac disease, as gluten can trigger harmful immune responses in affected individuals. This diet excludes all forms of wheat, barley, rye, and oats unless they are labeled gluten-free.
Choice B reason: A high-fiber diet is generally healthy but is not specifically related to the management of celiac disease. During exacerbations, it is more important to ensure that all foods are gluten-free to avoid triggering symptoms.
Choice C reason: There is no need for a low-protein diet in celiac disease management. Protein is not related to the immune response triggered by gluten.
Choice D reason: Wheat flour contains gluten and must be avoided in a gluten-free diet. Alternative flours such as rice, corn, or gluten-free blends should be used instead.
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