The nurse is caring for a client who has just been admitted for vaso-occlusive sickle cell crisis. The client's Vital signs are: HR 1 10/min, BP 138/82, RR 22, Sp02 97% on 2 liters oxygen by nasal cannula. T. 98.8. pain 10/10 to the left lower extremity. Which of the following actions should the nurse take first?
Increase oxygen to 6 liters per minute.
Administer PRN Morphine Sulfate IV push for pain.
Request an order for a PRN antihypertensive medication.
Begin administering prescribed IV fluids.
The Correct Answer is B
A. The client’s SpO2 is already at 97%, so increasing oxygen is unnecessary. Oxygen is only required if hypoxia is present.
B. Pain management is the priority in vaso-occlusive crisis. Severe pain leads to stress, increasing oxygen demand and worsening sickling. IV opioids (e.g., morphine) are the standard treatment.
C. The BP is elevated but not critically high, and pain-related stress may be contributing. Treating pain first is the priority.
D. IV fluids help with hydration and reducing sickling, but pain management should be addressed first to provide immediate relief.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. A positive ELISA test requires confirmation with a more specific test, such as a Western blot or indirect immunofluorescence assay (IFA), to rule out false positives.
B. A positive ELISA does not indicate the absence of HIV; further testing is needed for confirmation.
C. HIV testing does not involve direct visualization of infected cells under a microscope.
D. HIV can still be transmitted at any stage, even if symptoms are not present.
Correct Answer is C
Explanation
A. Warfarin is an anticoagulant and could worsen bleeding; it is contraindicated in GI bleeding cases.
B. Vitamin D is essential for bone health but does not directly treat anemia.
C. Iron supplements are commonly prescribed for anemia due to GI bleeding because chronic blood loss leads to iron deficiency. Iron supplementation helps replenish iron stores necessary for RBC production.
D. Zidovudine is an antiretroviral medication used for HIV treatment and is unrelated to anemia from GI bleeding.
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