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 B
Explanation
A. While abdominal surgery may be needed in some cases of intussusception, non-surgical interventions are often attempted first.
B. An enema with air infusion (often a contrast enema) can be used to treat intussusception by helping to unfold the intestine, making it a commonly discussed procedure.
C. An ano-rectal pull-through procedure is not related to intussusception and is usually indicated for conditions like Hirschsprung's disease.
D. A colostomy may be necessary in cases of bowel necrosis or perforation but is not the first-line treatment for intussusception.
Correct Answer is ["10"]
Explanation
To calculate the dosage of ondansetron for the child, first convert the child's weight from pounds to kilograms, knowing that 1 kilogram equals 2.2 pounds. The child weighs 44 lbs, which is equivalent to 20 kg (44 lbs / 2.2 lbs per kg). The prescribed dose is 0.5 mg/kg, so you would multiply the child's weight in kilograms by the dose: 20 kg * 0.5 mg/kg = 10 mg. Since the safe dose is up to 5 mg/kg per dose and the child's weight is 20 kg, the maximum safe dose would be 100 mg (20 kg * 5 mg/kg). Therefore, the nurse should administer 10 mg, as it is within the safe dose range.
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