How can the nurse determine that the outcomes of nursing interventions have been successful for the client diagnosed with a sickle cell crisis? (SELECT ALL THAT APPLY)

The client is free of chest pain and dyspnea.

The client describes the importance of increasing fluid intake.

The client increases aerobic exercises to promote endurance.

The client's acute pain is controlled at 3 on a standard pain scale.

Answer and Explanation

Correct Answer : A,B,D

Choice A reason:
Being free of chest pain and dyspnea is a significant indicator of successful nursing intervention in a sickle cell crisis. Chest pain and dyspnea can occur due to acute chest syndrome, a life-threatening complication of sickle cell disease characterized by vaso-occlusion in the pulmonary microcirculation. Effective pain management and oxygen therapy can alleviate these symptoms, reflecting improved respiratory function and gas exchange.

Choice B reason:
Educating the client on the importance of increasing fluid intake is crucial in managing sickle cell crisis. Adequate hydration helps to reduce blood viscosity and prevent sickling of red blood cells, which can lead to vaso-occlusive episodes. When a client verbalizes understanding and the importance of hydration, it demonstrates the effectiveness of patient education and the client's engagement in self-care.

Choice C reason:
While increasing aerobic exercises may promote endurance, it is not typically a short-term outcome measure for a sickle cell crisis. Exercise must be approached with caution in these clients, as it can increase the risk of a vaso-occlusive crisis due to dehydration and increased oxygen demand during a sickle cell crisis.

Choice D reason:
Control of acute pain to a level of 3 on a standard pain scale indicates successful pain management, a primary goal in the treatment of sickle cell crisis. Pain in sickle cell crisis is due to ischemia from obstructed blood flow by sickled cells. Effective analgesic administration and pain management strategies are essential to achieve this outcome.

Choice E reason:
A leukocyte count of 18,000/mm³ is above the normal range (4,500 to 11,000/mm³) and may indicate an infection or inflammation, which are common complications of sickle cell disease. However, this is not a direct outcome of nursing interventions aimed at managing a sickle cell crisis and thus is not a correct choice.

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Correct Answer is B

Explanation

Choice A Reason
Bradycardia, which is a slower than normal heart rate, is not typically a sign of hypoglycemia. Hypoglycemia can actually cause an increase in heart rate due to the release of adrenaline in response to low blood sugar levels.

Choice B Reason
Tremors are a common sign of hypoglycemia and are caused by the release of adrenaline. When blood sugar levels fall too low, the body releases adrenaline as a part of the "fight or flight" response, which can lead to shaking or trembling.

Choice C Reason
Kussmaul's respirations, which are deep and labored breathing patterns, are more commonly associated with diabetic ketoacidosis, not hypoglycemia. This type of breathing is the body's response to acidosis and is not indicative of low blood sugar levels.

Choice D Reason
Polyuria, or excessive urination, is not a sign of hypoglycemia. It is more commonly associated with hyperglycemia, as the body attempts to eliminate excess glucose through urine.

A. Ceftriaxone, with a white blood cell count of 16,000 u/L. B. Zafirlukast, with an AST of 30 units/L and ALT of 20 units/L. C. Theophylline, with a theophylline level of 21 mg/dL. D. Prednisone, with a glucose level of 110 mg/dL.

Correct Answer is C

Explanation

Choice A Reason
Ceftriaxone is an antibiotic that may be prescribed during COPD exacerbations to treat or prevent infection. A white blood cell count of 16,000 u/L indicates an elevated level, which could be a response to infection. Therefore, ceftriaxone would be appropriate, and there is no need to question this medication based on the white blood cell count.

Choice B Reason
Zafirlukast is a leukotriene receptor antagonist used for the prophylactic treatment of asthma, and it may be used off-label for COPD. AST and ALT levels are liver enzymes, and the values provided (AST of 30 units/L and ALT of 20 units/L) are within normal ranges. Thus, there is no immediate concern regarding liver function that would prompt the nurse to question the use of zafirlukast.

Choice C Reason
Theophylline is a bronchodilator used in the treatment of COPD. However, a theophylline level of 21 mg/dL is above the therapeutic range, which is generally considered to be 5-15 mg/dL. Levels above 20 mg/dL are associated with toxicity and can lead to serious side effects such as seizures or arrhythmias. Therefore, the nurse should question this medication due to the high theophylline level.

Choice D Reason
Prednisone is a corticosteroid that may be used to reduce inflammation during COPD exacerbations. A glucose level of 110 mg/dL is slightly elevated but may be expected as corticosteroids can increase blood sugar levels. This would not typically be a reason to question the use of prednisone unless the patient has poorly controlled diabetes or other specific contraindications.

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