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
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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Related Questions
Correct Answer is C
Explanation
A. Administer the medication at mealtime.Ferrous sulfate is best absorbed on an empty stomach because food, especially those rich in calcium or tannins, can interfere with its absorption. Administering it with meals reduces its effectiveness.
B.While bedtime administration is not contraindicated, it is not necessary. The timing of administration should focus on maximizing absorption, typically between meals or on an empty stomach.
C. Ferrous sulfate can stain teeth if taken orally in liquid form. Using a straw minimizes contact with teeth, reducing the risk of discoloration. Parents should also be advised to encourage the child to rinse their mouth after taking the medication.
D. Dilute the medication with 240 mL of milk. Milk contains calcium, which inhibits the absorption of iron. Ferrous sulfate should not be taken with milk or dairy products to ensure optimal absorption.
Correct Answer is D
Explanation
A. Give the toddler a hard-tipped sippy cup to drink liquid:
Giving a toddler a hard-tipped sippy cup with a hard spout can increase the risk of injury, especially if the toddler falls while using it. Toddlers at this age are still developing coordination and may not have the motor skills to handle a hard-tipped cup safely. Therefore, this choice would not be appropriate and could potentially harm the toddler.
B. Suction the toddler nose and mouth every hour:
Frequent suctioning of the nose and mouth every hour can cause irritation and discomfort to the toddler. While suctioning may be necessary in certain medical situations, such as clearing mucus or secretions, it should not be done routinely every hour without a specific medical indication. Overuse of suctioning can damage the delicate tissues in the nose and mouth and disrupt the normal mucous membranes.
C. Maintain elbow restraint:
Maintaining elbow restraint is not a standard intervention for a toddler who is 24 hours post-intervention unless there is a specific medical reason for it, such as preventing the toddler from accessing an IV site or medical device. Restraining a toddler's elbows without a clear medical indication can be distressing for the child and may impede their ability to move and explore their environment, which is important for their development.
D. Provide soft foods for the toddler:
Providing soft foods for the toddler is the most appropriate intervention in this scenario. Soft foods are easier for toddlers to chew and swallow, reducing the risk of choking or discomfort, especially if the toddler has undergone certain interventions that may affect their ability to eat solid foods comfortably. Soft foods can include mashed fruits and vegetables, cooked grains, pureed meats, and other easily digestible options suitable for a toddler's age and developmental stage.
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