A nurse is planning care for an adolescent client who has sickle cell anemia and is experiencing a vaso-occlusive crisis. Which of the following interventions is the nurse's priority?
Applying heat to the affected areas
Administering prophylactic antibiotics
Administering the pneumococcal vaccine
Promoting bed rest
The Correct Answer is D
A. Applying heat to the affected areas: In vaso-occlusive crises associated with sickle cell disease, heat packs can be a helpful part of pain management, but they should be used with caution and not in all situations.
B. Administering prophylactic antibiotics: While prophylactic antibiotics are important in preventing infections in sickle cell anemia, this is not the immediate priority during a vaso-occlusive crisis.
C. Administering the pneumococcal vaccine: While vaccination is important, it is not a priority during a vaso-occlusive crisis.
D. Promoting bed rest: The nurse should assist the child to assume a comfortable position so that the child keeps the extremities extended to promote venous return; elevate the head of the bed no more than 30 degrees and avoid putting strain on painful joints.
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Related Questions
Correct Answer is C
Explanation
A. Educate the infant's caregiver about the feeding: While important, education should occur after ensuring the prescription is correct.
B. Flush the feeding tube before the feeding: This ensures patency but should only be done after verifying the prescription.
C. Clarify the feeding prescription with the provider. Bolus feedings are typically contraindicated with nasojejunal tubes because the jejunum cannot handle large volumes at once. Continuous feedings are usually prescribed. The prescription should be clarified before proceeding.
D. Place a label on the feeding bag and tubing: Labeling is necessary for safety but is not the priority when the prescription may be inappropriate.
Correct Answer is A
Explanation
A. "I can offer popcorn as a snack food." Popcorn is gluten-free and safe for children with celiac disease.
B. "I will make sandwiches on rye bread." Rye contains gluten and should be avoided.
C. "I will purchase graham crackers to pack in their lunchbox." Graham crackers often contain gluten and are unsuitable unless specifically labeled gluten-free.
D. "I can make beef barley soup for dinner." Barley contains gluten and is not safe for children with celiac disease.
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