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

Answer and Explanation

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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Correct Answer is A

Explanation

A. Initiate contact precautions: RSV is a highly contagious respiratory virus spread via droplets and direct contact. To prevent transmission to others, contact precautions should be initiated.
B. Perform chest percussion and postural drainage: While these techniques can be used in some respiratory conditions, they are not the first-line intervention for RSV.
C. Encourage clear liquids by mouth: While oral rehydration may be appropriate in some cases of mild dehydration, this infant is likely experiencing respiratory distress, and oral intake may be difficult. Intravenous fluids may be required, especially if the infant is having difficulty feeding.
D. Administer IV antibiotics: RSV is caused by a virus, not a bacterial infection, so antibiotics are not effective in treating the infection.

A. Feed infant in a supine position B. Offer smaller, more frequent feedings C. Thicken formula feedings with rice cereal D. Place infant in a side lying position for sleep.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"}}

Explanation

Feed infant in a supine position: Contraindicated

Supine feeding increases the risk of aspiration and exacerbates reflux.

Offer smaller, more frequent feedings: Appropriate

Smaller, frequent feedings reduce gastric distension and reflux episodes.

Thicken formula feedings with rice cereal: Appropriate

Thickened feedings can help reduce reflux by increasing the weight of the stomach contents.

Place infant in a side-lying position for sleep: Contraindicated

The recommended sleep position for infants is supine (on the back) to reduce the risk of sudden infant death syndrome (SIDS).

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for an infant who has respiratory syncytial virus (RSV) and a respiratory rate of 46/min. Which of the following interventions should the nurse include in the plan of care?

Correct Answer is A

Explanation

The nurse is continuing to care for the infant. The nurse is providing teaching to the parents of the infant. For each instruction, click to specify if the instruction is appropriate or contraindicated for the infant.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"}}

Explanation

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