A nurse is creating a plan of care for a child who has sickle cell anemia. Which of the following interventions should the nurse include in the plan?
Discourage a high level of fluid intake.
Administer meperidine every 4 hr for pain.
Apply cold compresses to painful, swollen joints.
Observe for indications of hypokalemia.
The Correct Answer is D
Choice A reason: Discouraging a high level of fluid intake is incorrect, as hydration is essential for preventing sickle cell crises and reducing blood viscosity. The nurse should encourage the child to drink at least 1.5 times the normal fluid requirement.
Choice B reason: Administering meperidine every 4 hr for pain is incorrect, as meperidine is not recommended for sickle cell pain due to the risk of neurotoxicity and seizures. The nurse should use other opioids such as morphine or hydromorphone for pain management.
Choice C reason: Applying cold compresses to painful, swollen joints is incorrect, as cold can cause vasoconstriction and worsen the sickling of red blood cells. The nurse should use warm compresses or heating pads to promote vasodilation and blood flow.
Choice D reason: Observing for indications of hypokalemia is correct, as sickle cell anemia can cause hemolysis and potassium loss. The nurse should monitor the child's serum potassium level and watch for signs of hypokalemia such as muscle weakness, cramps, arrhythmias, and constipation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Offering the child clear liquids for the first 24 hours is not necessary, as the child can resume a normal diet after the procedure. Clear liquids are only recommended for the first few hours after the procedure to prevent nausea and vomiting.
Choice B reason: Assisting the child to take a tub bath for the first 3 days is not advised, as it can increase the risk of infection and bleeding at the catheter insertion site. The child should avoid tub baths, swimming, and soaking the site until it is completely healed, which may take up to a week.
Choice C reason: Giving the child acetaminophen for discomfort is appropriate, as it can relieve the pain and soreness at the catheter insertion site. The child should avoid aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs), as they can increase the risk of bleeding.
Choice D reason: Keeping the child home for 1 week is not required, as the child can resume normal activities within a few days after the procedure. The child should avoid strenuous activities, such as running, jumping, and biking, for at least 24 hours after the procedure.
Correct Answer is B
Explanation
Choice A reason: Glyburide is an oral medication that lowers blood sugar by stimulating the pancreas to produce more insulin. It is not used for type 1 diabetes mellitus, as the pancreas cannot produce enough insulin in this condition. Glyburide is used for type 2 diabetes mellitus, which is caused by insulin resistance.
Choice B reason: Obtaining an influenza vaccine annually is recommended for people who have type 1 diabetes mellitus, as they are more prone to complications from the flu, such as pneumonia, ketoacidosis, and hospitalization. The vaccine can help prevent or reduce the severity of the flu and its complications.
Choice C reason: Injecting insulin in the deltoid muscle is not the best practice for administering insulin, as the absorption rate and onset of action may vary depending on the muscle mass and blood flow. The preferred sites for insulin injection are the abdomen, the upper arms, the thighs, and the buttocks, as they have more subcutaneous fat and less muscle tissue. The injection site should also be rotated to prevent lipodystrophy.
Choice D reason: Administering glucagon for hyperglycemia is not appropriate, as glucagon is a hormone that raises blood sugar by stimulating the liver to release glucose. It is used for hypoglycemia, or low blood sugar, which is a common and serious complication of type 1 diabetes mellitus. Hyperglycemia, or high blood sugar, is treated with insulin, fluids, and electrolytes.
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