A nurse is planning care for an adolescent client.
Apply cold compresses to the joints
Encourage bedrest
Provide oxygen at 6 min via nasal cannula
Restrict fluid intake to 1,400 mL/day.
Obtain consent for a blood transfusion.
Administer IV fluids.
Perform passive range-of-motion exercises.
Correct Answer : B,E,F
A. Cold compresses may not be appropriate in this case. In sickle cell crises, warmth is typically encouraged to promote circulation and reduce pain, whereas cold can constrict blood vessels and potentially worsen ischemia.
B. Bedrest is appropriate for this client to minimize energy expenditure and allow the body to focus on healing. Pain management is also a priority, and limiting activity can help manage pain levels.
C. While oxygen can be helpful in managing hypoxia, the client’s oxygen saturation is currently 96% on room air, indicating adequate oxygenation. Routine administration of oxygen is not indicated in this scenario.
D. In sickle cell disease, hydration is important to reduce blood viscosity and prevent crises. Therefore, the nurse should encourage adequate fluid intake unless contraindicated.
E. The client has a significantly low hemoglobin level (5 g/dL), which may necessitate a blood transfusion to improve oxygen-carrying capacity and treat anemia. Consent should be obtained as part of the preparation for this intervention.
F. Administering IV fluids is essential for rehydration and improving circulation, which can help alleviate pain and prevent further sickling of cells.
G. While passive range-of-motion exercises can be beneficial, they are generally not recommended during acute pain episodes as they may exacerbate discomfort and pain. The focus should be on pain management and rest.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Acute glomerulonephritis is characterized by the sudden onset of hematuria (reddish-brown urine), proteinuria (4+ protein), and a recent history of streptococcal infection, making it the most likely diagnosis.
B. Renal agenesis is a congenital condition and would not present suddenly with abdominal pain and hematuria.
C. Nephrotic syndrome typically presents with significant proteinuria, but the acute onset of symptoms and recent strep throat history point more toward glomerulonephritis.
D. Polycystic kidney disease usually presents with abdominal or flank pain, hypertension, and hematuria over a more chronic course, not typically after an acute infection.
Correct Answer is B
Explanation
A. Keeping a written document of the treatment plan is essential for ensuring continuity of care and effective communication with healthcare providers.
B. Parents should notify their provider immediately, rather than waiting for the next business day, if their child has a sore throat, as this could indicate a possible infection in an immunocompromised child.
C. Using acetaminophen is generally appropriate for managing pain or fever in children receiving chemotherapy, but it should be done with caution regarding dosage and timing.
D. Maintaining a written list of medical appointments helps keep track of the child’s care and is a good practice for managing their health.
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