The client with sickle cell disease (SCD) has recently been sick and is now experiencing a vaso-occlusive crisis. Which priority interventions should the nurse implement?
Encourage frequent ambulation in the hallways
Monitor the client's RBC count every 4 hours
Treat them in an outpatient setting
Maintain IV fluids, administer pain medications, and provide supplemental oxygen
The Correct Answer is D
A. Encouraging frequent ambulation is not appropriate during a vaso-occlusive crisis, as it can exacerbate pain and further compromise blood flow.
B. While monitoring the RBC count is important, it is not the most immediate intervention during a crisis. The focus should be on managing pain and preventing complications.
C. Treating the client in an outpatient setting is inappropriate during a vaso-occlusive crisis, which typically requires inpatient care for effective pain management and hydration.
D. Maintaining IV fluids, administering pain medications, and providing supplemental oxygen are critical interventions that address the acute needs of the client in crisis, aiming to alleviate pain and improve oxygenation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Decreasing intake of foods high in fiber is not necessary; in fact, fiber can help prevent constipation, a common side effect of iron supplements.
B. Vitamin C actually enhances the absorption of iron; thus, avoiding it is incorrect. Clients should be encouraged to consume vitamin C alongside their iron supplements to improve absorption.
C. Stools becoming darker in color is a common and expected side effect of ferrous sulfate due to the presence of unabsorbed iron. It is important for clients to know this to avoid unnecessary alarm.
D. Taking the medication on a full stomach may decrease absorption; it is generally recommended to take iron supplements on an empty stomach for optimal absorption unless gastrointestinal upset occurs.
Correct Answer is A
Explanation
A. Viral load count is the primary test used to assess the effectiveness of HIV therapy by measuring the amount of HIV RNA in the blood, indicating how well the treatment is controlling the virus.
B. The Western blot is used as a confirmatory test for HIV diagnosis rather than monitoring therapy effectiveness.
C. The Enzyme immunoassay (EIA) test is used for initial HIV screening but does not measure viral load or therapy effectiveness.
D. Platelet count can be affected in HIV infection, especially with advanced disease, but it does not directly measure the effectiveness of HIV therapy.
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