A school-age child is admitted in vaso-occlusive sickle cell crisis. The child's care should include which intervention? (Select all that apply.).
Correction of acidosis.
Adequate hydration.
Pain management.
Administration of heparin.
Replacement of factor VIII.
Correct Answer : B,C,E
Choice A rationale:
Correction of acidosis is not the primary intervention for vaso-occlusive sickle cell crisis. The crisis primarily involves pain due to the obstruction of blood flow by sickled cells. Correcting acidosis is not a direct treatment for this condition.
Choice B rationale:
Adequate hydration is essential in managing vaso-occlusive sickle cell crisis. Proper hydration helps prevent dehydration, which can worsen the crisis and lead to complications. Hydration helps maintain blood flow and prevent further sickling of red blood cells.
Choice C rationale:
Pain management is a crucial intervention for a child with vaso-occlusive sickle cell crisis. Pain results from tissue ischemia caused by sickled red blood cells. Effective pain management, often with analgesics, helps improve the child's comfort and quality of life during the crisis.
Choice D rationale:
Administration of heparin is not indicated for vaso-occlusive sickle cell crisis. Heparin is an anticoagulant that prevents blood clot formation. In sickle cell crisis, the primary issue is the obstruction of blood flow by sickled cells, not the formation of clots. Administering heparin may not address the underlying problem and can lead to potential complications.
Choice E rationale:
Replacement of factor VIII is not relevant to vaso-occlusive sickle cell crisis. Factor VIII is a protein involved in blood clotting and is primarily used in the treatment of hemophilia, a different condition unrelated to sickle cell crisis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
A respiratory rate of 10 bpm (breaths per minute) is significantly below the normal range for an adult but is within the normal range for a newborn. Since the question does not specify the client's age, this information is insufficient to identify it as a complication of magnesium sulfate administration.
Choice B rationale:
A blood pressure of 148/94 is elevated and could be a complication of magnesium sulfate administration. Magnesium sulfate is used to manage pregnancy-induced hypertension, so if the blood pressure remains high or increases further, it could indicate an inadequate response to the treatment or a potential complication.
Choice C rationale:
Deep tendon reflexes of +2 are within the normal range and are not indicative of a complication related to magnesium sulfate administration. In fact, magnesium sulfate can cause muscle weakness and decreased deep tendon reflexes, so an absence of reflexes or extremely diminished reflexes might be a cause for concern.
Choice D rationale:
A urine output of 70 ml/hour is within the normal range for an adult, but without additional information, it is not indicative of a complication related to magnesium sulfate administration. Monitoring urine output is essential to assess renal function and fluid balance, but in this context, it does not provide specific information about the effects of magnesium sulfate.
Correct Answer is ["D","E"]
Explanation
E.
Choice A rationale:
Administer antibiotics. Rationale: Antibiotics are not indicated for respiratory syncytial virus (RSV) bronchiolitis, which is caused by a viral infection. RSV is a common cause of bronchiolitis in infants, and antibiotics do not treat viral infections. Using antibiotics in this situation would not be appropriate and can contribute to antibiotic resistance.
Choice B rationale:
Administer cough syrup. Rationale: Cough syrups are generally not recommended for infants and young children due to the risk of overdosing and potential adverse effects. Additionally, RSV bronchiolitis primarily requires supportive care and management of respiratory symptoms, which may include oxygen therapy in severe cases.
Choice C rationale:
Encourage infant to drink 8 ounces of formula every 4 hours. Rationale: Maintaining hydration is essential in the management of RSV bronchiolitis. However, the specific volume and frequency of formula intake may vary based on the infant's age, weight, and overall condition. It is important to assess the infant's tolerance and adjust the feeding schedule accordingly. Encouraging frequent, smaller feeds might be more appropriate for some infants to prevent overfeeding and vomiting.
Choice D rationale:
Institute cluster care to encourage adequate rest. Rationale: Cluster care, a nursing intervention involving grouping activities to minimize disturbances and promote longer periods of rest, is beneficial for infants with RSV bronchiolitis. Adequate rest helps conserve the infant's energy, facilitating the recovery process. This intervention supports the infant's overall well-being and aids in coping with respiratory distress.
Choice E rationale:
Place on noninvasive oxygen monitoring. Rationale: Infants with severe RSV bronchiolitis may experience respiratory distress and hypoxia, necessitating oxygen therapy. Noninvasive oxygen monitoring methods, such as pulse oximetry, allow healthcare providers to assess oxygen saturation levels without invasive procedures. Oxygen therapy can improve oxygenation and alleviate respiratory distress, supporting the infant's respiratory function and overall recovery.
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