A nurse is caring for an adolescent who is having a sickle cell crisis. Which of the following nursing actions should the nurse take?

withhold opioids to avoid dependence

Assist RN with administering a blood transfusion

Initiate a 2 L/day fluid restriction

Encourage exercise

Answer and Explanation

The Correct Answer is B

A. Withhold opioids to avoid dependence.

This option is incorrect. Opioid analgesics are commonly used to manage the severe pain associated with sickle cell crisis. Withholding opioids during a crisis could lead to inadequate pain relief and compromise the adolescent's comfort and recovery. It's important to appropriately administer opioids as prescribed to alleviate pain and suffering.

B. Assist RN with administering a blood transfusion.

This option may be appropriate depending on the severity and indications of the sickle cell crisis. Blood transfusions are sometimes used to treat sickle cell crises, particularly in cases of severe anemia or acute complications such as acute chest syndrome. However, the decision to administer a blood transfusion should be made by the healthcare provider based on the individual patient's clinical status and needs. The nurse's role would include assisting the registered nurse (RN) with the administration of the transfusion and monitoring the adolescent for any adverse reactions.

C. Initiate a 2 L/day fluid restriction.

This option is incorrect. During a sickle cell crisis, it is important to maintain adequate hydration to help prevent dehydration and reduce the viscosity of blood, which can help prevent sickling of red blood cells. Fluid intake should be encouraged, and there is typically no need for fluid restriction unless there are specific medical reasons to do so.

D. Encourage exercise.

This option is incorrect. During a sickle cell crisis, the adolescent is likely experiencing significant pain and discomfort, which may limit their ability to engage in physical activity. Encouraging exercise during a crisis could exacerbate pain and potentially lead to complications. Rest and minimizing physical exertion are typically recommended during a sickle cell crisis to promote comfort and conserve energy.

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Correct Answer is ["C","D"]

Explanation

A. Keep the infant in a side-lying position.

This intervention is not appropriate following cleft palate repair surgery. Placing the infant in a side-lying position may increase the risk of trauma to the surgical site and disrupt the healing process. It's important to follow the surgeon's recommendations regarding positioning, which typically involves keeping the infant in an upright position to minimize strain on the surgical site.

B. Remove elbow restraints while the infant is sleeping.

Elbow restraints are often used postoperatively to prevent the infant from accidentally touching or rubbing the surgical site, which could disrupt wound healing or cause discomfort. Removing the restraints while the infant is sleeping may increase the risk of unintended movement or injury to the surgical site. Therefore, it is not appropriate to remove the restraints while the infant is sleeping.

C. Administer pain medication around the clock for the first 72 hours.

This intervention is appropriate. Pain management is an essential component of postoperative care following cleft palate repair surgery. Administering pain medication around the clock helps to maintain consistent pain relief and prevent spikes in discomfort. Pain management should be tailored to the individual needs of the infant and may include both non-pharmacological measures and analgesic medications.

D. Feed the infant half-strength formula for the first 48 hours.

This intervention is appropriate. Following cleft palate repair surgery, feeding may need to be adjusted to accommodate the infant's comfort and ensure adequate nutrition while minimizing the risk of aspiration. Feeding the infant half-strength formula or other appropriate feeding methods as recommended by the healthcare provider can help prevent stress on the surgical site and reduce the risk of complications such as aspiration pneumonia.

A. 33.6 mg B. 18.7 mg C. 8.4 mg D. 19 mg

Correct Answer is B

Explanation

To calculate the appropriate dose of Theophylline for the child weighing 4.69 kg:

Dose = Weight (kg) × Dose (mg/kg)

Dose = 4.69 kg × 4 mg/kg

Dose = 18.76 mg

So, the appropriate dose is approximately 18.7 mg.

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A nurse is caring for an adolescent who is having a sickle cell crisis. Which of the following nursing actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for a 2-month-old infant who has just undergone cleft palate repair. The nurse should contribute which of the following interventions to the client's plan of care?

Correct Answer is ["C","D"]

Explanation

A child with asthma has the following medication ordered: Theophylline 4 mg/kg/dose every 6 hrs. The child weighs 4.69 kg. Calculate the appropriate dose.

Correct Answer is B

Explanation

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