A nurse is preparing to develop a plan of care for a school-aged child who has been diagnosed with sickle cell anemia. Which of the following findings should the nurse include in the plan of care?
The child has a normal potassium level.
The child has a low hemoglobin level.
The child has a high platelet level.
The child has a low blood glucose level.
The Correct Answer is B
Choice A reason: The child has a normal potassium level, as it is within the reference range of 3.5 to 5 mEq/L. Potassium is an electrolyte that helps regulate the fluid balance, nerve impulses, and muscle contractions in the body.
Choice B reason: The child has a low hemoglobin level, as it is below the reference range of 10 to 15.5 g/dL. Hemoglobin is a protein in the red blood cells that carries oxygen to the tissues. Sickle cell anemia is a genetic disorder that causes the red blood cells to have an abnormal shape and become rigid, sticky, and prone to clumping. This can lead to hemolysis, anemia, and reduced oxygen delivery.
Choice C reason: The child has a normal platelet level, as it is within the reference range of 150,000 to 450,000 mm^3^. Platelets are blood cells that help with clotting and prevent bleeding. Sickle cell anemia can cause thrombocytopenia, a low platelet count, due to increased destruction or sequestration of platelets in the spleen.
Choice D reason: The child has a normal blood glucose level, as it is within the reference range of 70 to 110 mg/dL. Blood glucose is the main source of energy for the cells in the body. Sickle cell anemia can cause hypoglycemia, a low blood glucose level, due to impaired glucose metabolism, increased glucose utilization, or decreased glucose production.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: This statement is incorrect, as giving an oral rehydration solution to an infant who is projectile vomiting may worsen the dehydration and electrolyte imbalance. The nurse should advise the parent to stop feeding the infant and seek medical attention.
Choice B reason: This statement is incorrect, as burping the baby more frequently during feedings may not prevent the projectile vomiting, which is caused by a mechanical obstruction of the stomach, not by air swallowing. The nurse should assess the parent for signs of pyloric stenosis, such as a palpable olive-shaped mass in the right upper quadrant of the abdomen.
Choice C reason: This statement is correct, as bringing the baby in to the clinic today is the best course of action for an infant who is projectile vomiting, which is a sign of a serious condition such as pyloric stenosis, a narrowing of the opening between the stomach and the small intestine. The nurse should inform the parent that the infant needs immediate evaluation and treatment to prevent complications such as dehydration, malnutrition, and metabolic alkalosis.
Choice D reason: This statement is incorrect, as trying switching to a different formula may not help the infant who is projectile vomiting, which is not related to the type of formula, but to a structural problem in the gastrointestinal tract. The nurse should not suggest changing the formula without consulting the provider.
Correct Answer is A
Explanation
Choice A reason: This is the best option to prevent reflux, as it allows gravity to help keep the stomach contents down. The nurse should advise the parent to keep the baby upright for at least 30 minutes after each feeding.
Choice B reason: Positioning the baby side lying during sleep is not recommended, as it can increase the risk of sudden infant death syndrome (SIDS). The nurse should instruct the parent to place the baby on the back for sleep, and elevate the head of the crib slightly.
Choice C reason: Thickening the baby's formula with oatmeal may help reduce reflux, but it is not the first choice, as it can cause overfeeding, constipation, or allergic reactions. The nurse should suggest this option only if prescribed by the provider.
Choice D reason: Feeding the baby formula rather than breast milk is not a good option, as breast milk is easier to digest and has many benefits for the baby's health and development. The nurse should encourage the parent to continue breastfeeding, and offer smaller and more frequent feedings.
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