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","B","C","D","E","F"]
Explanation
A. Avoiding bubble baths is important as they can irritate the urethra and exacerbate UTIs.
B. Wiping the perineal area from front to back is essential to prevent bacteria from the rectal area from entering the urinary tract.
C. Completing the course of prescribed antibiotics is crucial to fully eradicate the infection and prevent recurrence.
D. Encouraging frequent voiding helps to flush out bacteria from the urinary tract and prevent infection.
E. Wearing cotton underwear helps keep the area dry and reduce the risk of bacterial growth.
F. Encouraging frequent fluid intake aids in hydration and helps dilute the urine, reducing irritation and promoting flushing of bacteria.
Correct Answer is D
Explanation
A. Deflecting the question to the doctor does not provide the patient with helpful information and shows a lack of communication.
B. While the test can indicate renal impairment, it is more accurate to say it assesses overall kidney function rather than confirming a specific disease.
C. Although medications can affect kidney function, the serum creatinine level is not specifically for evaluating medication interference.
D. The serum creatinine test is a standard measure of kidney function, indicating how well the kidneys are filtering waste from the blood.
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