Before leaving the room of a client who is confused, the nurse observes that a half bow knot was used to attach the client's wrist restraints to the movable portion of the client's bed frame. Which action should the nurse take before leaving the room?

Rationale for Correct Choices:

• Sickle cell crisis: The infant’s pallor, edema in hands and feet, irritability, poor feeding, decreased urine output, and recent infection align with a vaso-occlusive episode typical in sickle cell disease.

•IV and oral fluids decrease blood viscosity and improve circulation, which is essential to prevent worsening of vaso-occlusion and associated pain.

• As able, elevate extremities: Elevating affected extremities promotes venous return, reduces swelling, and alleviates discomfort during the crisis.

• Intake and output: Monitoring fluid balance is critical to detect dehydration or renal compromise, which are risks in sickle cell crises due to reduced perfusion and poor intake.

• White blood cell count: WBC monitoring helps detect infection, which can trigger or worsen a sickle cell crisis, and assesses the body’s inflammatory response during the acute event.

Rationale for Incorrect Choices:

• Leukemia: While leukemia can present with pallor and fatigue, the acute swelling of hands and feet, irritability, and trigger by recent infection are more characteristic of sickle cell crisis rather than leukemia.

• Pneumonia: Adventitious lung sounds are noted, but the primary presenting signs (pallor, extremity edema, decreased urine output, pain) are more consistent with sickle cell crisis; pneumonia alone would not explain extremity edema.

• Potential Condition: Stroke: Stroke in infants may cause focal neurological deficits or asymmetric movement, but this infant shows generalized extremity involvement without focal weakness, making stroke less likely.

• Initiate sliding scale insulin: There is no evidence of hyperglycemia requiring insulin; blood glucose monitoring is not indicated for the acute presentation.

• Cool the environment: Cooling can worsen vasoconstriction and precipitate a sickle cell crisis; it is contraindicated in vaso-occlusive episodes.

• Begin bilirubin light therapy: The infant does not present with jaundice or hyperbilirubinemia; phototherapy is not indicated.

• Blood glucose: There is no indication of hypoglycemia or hyperglycemia contributing to this presentation, so monitoring glucose is not priority.

• Clotting times: There is no evidence of coagulopathy or bleeding disorder in this scenario; monitoring clotting times is unnecessary.

• Bilirubin: The infant has no jaundice or lab evidence of hyperbilirubinemia, making bilirubin monitoring nonessential.

A. Soft abdomen, absent bowel sounds, no bleeding on dressing: This provides relevant post-operative assessment information, but it reflects the current status rather than additional history affecting immediate care priorities.

B. Peripheral pulses present with full range of motion of both legs: This is important for neurovascular assessment, but it is already covered in routine PACU reporting and does not represent additional critical information.

C. Declining to take ice chips despite reporting of dry mouth: While this may affect hydration and comfort, it does not significantly alter immediate post-operative management and can be addressed by the receiving nurse.

D. History of vomiting at home for 3 days prior to surgery: This is significant additional information because prolonged preoperative vomiting can lead to fluid and electrolyte imbalances, increasing the risk for complications post-operatively. The receiving nurse needs to be aware to guide monitoring and interventions.