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. Apical:
The apical pulse is the most reliable location to assess the pulse in infants. It is located at the apex of the heart, which is typically found at the fifth intercostal space at the midclavicular line. Assessing the apical pulse allows for a direct measure of the heart rate and rhythm, which is especially important in infants to evaluate cardiac function accurately. The apical pulse is commonly assessed using a stethoscope placed at the point of maximum impulse (PMI) on the chest.
B. Dorsalis pedis:
The dorsalis pedis pulse is located on the top of the foot, typically in the region between the first and second metatarsal bones. While the dorsalis pedis pulse can be palpated in older children and adults, it may be difficult to palpate accurately in infants, especially those with smaller or more delicate feet. Therefore, it is not the preferred site for pulse assessment in infants.
C. Temporal:
The temporal pulse is located on the side of the head, just above the ear. While the temporal pulse can be palpated in some individuals, it is not typically used to assess the pulse in infants. Palpating the temporal pulse in infants may be more challenging and less reliable compared to other pulse sites, especially given the smaller size of the temporal artery in infants.
D. Carotid:
The carotid pulse is located in the neck, alongside the trachea, and can be palpated by gently pressing the fingers against the carotid artery. While the carotid pulse is easily palpable in adults and older children, it is not typically the preferred site for pulse assessment in infants. Palpating the carotid pulse in infants carries a risk of injury to the delicate structures in the neck and may not provide an accurate representation of the pulse rate.
Correct Answer is D
Explanation
A. Restrain the toddler for 1 hr after the procedure:
This choice involves restraining the toddler for a period of time after the lumbar puncture procedure. However, restraining a toddler for such a prolonged period is not typically necessary and may cause distress and discomfort to the child. Moreover, prolonged restraint is not recommended as it can hinder the child's mobility and may lead to emotional distress.
B. Swaddle the toddler in a warm blanket:
Swaddling a toddler in a warm blanket may provide comfort, but it is not directly relevant to the lumbar puncture procedure itself. While comfort measures are important for overall patient care, they should not replace or interfere with the specific positioning requirements for medical procedures like a lumbar puncture.
C. Ask another nurse to assist with holding the toddler in a prone position:
This choice involves having another nurse assist in holding the toddler in a prone (face-down) position during the lumbar puncture procedure. However, the prone position is not typically used for lumbar punctures in toddlers. Placing the toddler in a prone position might make the procedure more challenging and less safe for both the child and the healthcare provider.
D. Place the toddler in a side-lying knee-chest position:
Placing the toddler in a side-lying knee-chest position is the correct action for a lumbar puncture procedure in a toddler. This position maximizes the space between the vertebrae, making it easier for the healthcare provider to access the lumbar area safely and accurately. It also helps minimize the risk of injury and discomfort for the toddler during the procedure. Therefore, this choice is the most appropriate for ensuring the success and safety of the lumbar puncture procedure.
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