A nurse is contributing to the plan of care for a client during a sickle cell crisis. Which of the following interventions should the nurse recommend?
Ambulate the client every 1 hr.
Apply cold compresses to painful joints.
Withhold opioids until the crisis is resolved.
Administer oxygen via nasal cannula.
The Correct Answer is D
Choice A reason: This is an incorrect intervention, because ambulating the client every 1 hr can increase the oxygen demand and worsen the sickling of the red blood cells.
Choice B reason: This is an incorrect intervention, because applying cold compresses to painful joints can cause vasoconstriction and reduce the blood flow to the affected areas.
Choice C reason: This is an incorrect intervention, because withholding opioids until the crisis is resolved can cause unnecessary suffering and increase the stress response, which can trigger more sickling.
Choice D reason: This is the correct intervention, because administering oxygen via nasal cannula can improve the oxygen saturation and prevent further sickling of the red blood cells.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This is the correct intervention, because avoiding IM injections can prevent bleeding and hematoma formation in the client who has low platelet count and impaired clotting.
Choice B reason: This is an incorrect intervention, because obtaining a rectal temperature once per shift can cause trauma and bleeding in the rectal mucosa, which is highly vascularized and sensitive.
Choice C reason: This is an unnecessary intervention, because the client who has thrombocytopenia does not have an increased risk of infection, unless they also have neutropenia or immunosuppression. The client should be allowed to have visitors, as long as they follow the infection control precautions.
Choice D reason: This is an incorrect intervention, because encouraging daily flossing between teeth can cause gingival bleeding and ulceration in the client who has low platelet count and impaired clotting. The client should use a soft toothbrush and avoid dental floss.
Correct Answer is A
Explanation
Choice A reason: This is the correct meal selection, because chicken breast and corn on the cob are low in cholesterol and saturated fat, which can help lower the risk of heart disease.
Choice B reason: This is an incorrect meal selection, because shrimp and rice are high in cholesterol and refined carbohydrates, which can increase the blood cholesterol and glucose levels.
Choice C reason: This is an incorrect meal selection, because cheese omelet and turkey bacon are high in cholesterol and sodium, which can raise the blood pressure and worsen the cardiac function.
Choice D reason: This is an incorrect meal selection, because liver and onions are high in cholesterol and iron, which can contribute to the formation of plaque and clots in the arteries.
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