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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Lethargy: Lethargy can be a concerning sign in a postoperative child, especially following a procedure involving the central nervous system like VP shunt insertion. It could indicate increased intracranial pressure or other neurological complications, which require immediate attention. Therefore, this is a priority finding.
B. Urine output 70 mL in 2 hr: While monitoring urine output is important for assessing hydration and renal function, a urine output of 70 mL in 2 hours may not be immediately concerning in a 4-year-old child. However, if this pattern continues or if there are signs of dehydration, it should be addressed. It's not as urgent as assessing for neurological changes.
C. Lying flat on the unaffected side: The positioning of the child, lying flat on the unaffected side, may or may not be concerning depending on the specific instructions provided postoperatively. While positioning can affect the function of the VP shunt, it may not necessarily indicate an immediate complication.
D. Respiratory rate 20/min: A respiratory rate of 20 breaths per minute is within the normal range for a 4-year-old child. While changes in respiratory rate can indicate respiratory distress, this respiratory rate alone is not immediately concerning.
Correct Answer is ["B","C"]
Explanation
A. "You should begin to manipulate the infant's bedtime based on the hospital's visiting hours."
This statement is incorrect. Manipulating the infant's bedtime based on hospital visiting hours may disrupt the infant's regular sleep schedule, potentially causing discomfort and distress. It's important to maintain the infant's routine as much as possible to promote comfort and well-being.
B. "You should bring the infant's favorite blanket to the hospital."
This statement is correct. Bringing the infant's favorite blanket or comfort item can provide familiarity and comfort during the hospital stay. Having familiar items from home can help soothe the infant and reduce anxiety associated with the new environment.
C. "You should read the child a story about hospitalization."
This statement is correct. Reading a story about hospitalization to the child can help prepare them for the upcoming experience and alleviate fear or anxiety. Choosing age-appropriate books that explain what to expect during a hospital stay can help normalize the experience and provide reassurance to the infant and parents.
D. "You will need to go home when it is not visiting hours."
This statement is incorrect. Parents are typically allowed to stay with their infant throughout the hospitalization, especially in the case of pediatric patients. Family presence is important for providing comfort and support to the infant and facilitating bonding during the hospital stay.
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