A nurse is contributing to the plan of care for an adolescent client who has sickle cell anemia and is experiencing a vaso-occlusive crisis. Which of the following interventions should the nurse include in the plan?

Decrease daily oral fluid intake.

Maintain bed rest to prevent hypoxemia.

Apply cold compresses to painful joints.

Administer meperidine to eliminate a fever.

Answer and Explanation

The Correct Answer is B

Choice A rationale:
Decrease daily oral fluid intake. Rationale: This choice is not appropriate for a client experiencing a vaso-occlusive crisis in sickle cell anemia. In this crisis, there is a risk of dehydration due to increased fluid loss, and decreasing oral fluid intake would exacerbate this issue. Adequate hydration is important to prevent further sickling of red blood cells and maintain organ perfusion.
Choice B rationale:
Maintain bed rest to prevent hypoxemia. Rationale: This is the correct choice. During a vaso-occlusive crisis in sickle cell anemia, blood flow to certain tissues is restricted, leading to tissue hypoxia and pain. Bed rest is recommended to reduce metabolic demands and oxygen consumption, helping to prevent further tissue damage and improve oxygenation. It also reduces the risk of complications such as thrombosis and respiratory compromise.
Choice C rationale:
Apply cold compresses to painful joints. Rationale: Applying cold compresses is not a recommended intervention for vaso-occlusive crisis in sickle cell anemia. Cold can exacerbate vasoconstriction and further compromise blood flow to the affected tissues. Warm compresses or warm baths might be more appropriate to promote vasodilation and alleviate pain.
Choice D rationale:
Administer meperidine to eliminate a fever. Rationale: Administering meperidine solely to eliminate a fever is not the primary focus of care for a vaso-occlusive crisis. The priority is to manage pain and improve tissue perfusion. Meperidine is an opioid analgesic that can be used to manage severe pain associated with sickle cell crises, but it should be given with caution due to the risk of respiratory depression and the potential for addiction.

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Correct Answer is C

Explanation

Choice A rationale:
Cleaning the infant's suture line with chlorhexidine solution is not indicated immediately after cleft lip repair. The primary concern in the immediate postoperative period is pain management and wound healing, and cleaning the suture line with chlorhexidine could potentially disrupt the healing process.
Choice B rationale:
Applying elbow immobilizers to the infant is not necessary after cleft lip repair. Elbow immobilizers are typically used in situations where there's a need to restrict arm movement, such as preventing a child from bending their arms after certain types of surgery. Cleft lip repair does not involve the arms, so this action is not relevant.
Choice C rationale:
Correct Choice. Offering the infant a pacifier with sucrose for pain relief is appropriate. Non-nutritive sucking, such as using a pacifier, has been shown to have pain-relieving effects in infants. Sucrose, a sweet solution, is often used in combination with non-nutritive sucking to further enhance pain relief during minor procedures or painful experiences. It provides comfort and distraction to the infant, helping to reduce their discomfort.
Choice D rationale:
Placing the infant in a prone position for sleeping is contraindicated after cleft lip repair. Placing an infant prone (on their stomach) for sleep increases the risk of sudden infant death syndrome (SIDS). The recommended sleep position for infants is supine (on their back) to ensure their safety.

A. "You should give your baby a pacifier when she cries." B. "Your baby will be placed in elbow restraints following surgery." C. "Your baby cannot have anything by mouth until 2 hours after surgery." D. "You should position your baby on her abdomen following surgery.".

Correct Answer is B

Explanation

The correct answer is choiceb. “Your baby will be placed in elbow restraints following surgery.”

Choice A rationale:

Giving a pacifier to a baby after cleft lip surgery is generally not recommended as it can put pressure on the surgical site and potentially disrupt the healing process.

Choice B rationale:

Elbow restraints are used to prevent the infant from touching or rubbing the surgical site, which helps in protecting the stitches and ensuring proper healing.

Choice C rationale:

Infants are usually allowed to have fluids by mouth soon after surgery, often within a few hours, to ensure they stay hydrated and to monitor their ability to swallow.

Choice D rationale:

Positioning the baby on their abdomen is not recommended as it can put pressure on the surgical site.Instead, the baby should be positioned on their back or side to avoid any pressure on the repaired lip

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A nurse is contributing to the plan of care for an adolescent client who has sickle cell anemia and is experiencing a vaso-occlusive crisis. Which of the following interventions should the nurse include in the plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with caring for an infant immediately postoperative following a cleft lip repair. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is reinforcing teaching with the parents of a 10-week-old infant who is scheduled for surgical repair of a cleft lip. Which of the following pieces of information should the nurse include?

Correct Answer is B

Explanation

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