The nurse is providing care to an infant with sickle cell anaemia who has increased work of breathing, a fever, coarse crackles upon auscultation, oxygen saturation of 89%, and inconsolable crying. Which intervention will the nurse perform first?

Prepare to hang hypotonic fluids.

Administer oxygen via nasal cannula.

Provide patient education on acute chest syndrome.

Give a dose of morphine sulphate.

Answer and Explanation

The Correct Answer is B

Choice A reason: Preparing to hang hypotonic fluids is not the immediate priority in this situation. While hydration is important for managing sickle cell anaemia, the infant's respiratory distress and low oxygen saturation levels indicate that addressing oxygenation should be the first step. Hypotonic fluids may be considered after stabilizing the patient's breathing and oxygen levels.

Choice B reason: Administering oxygen via nasal cannula is the priority intervention given the infant's symptoms. The infant has increased work of breathing, a fever, coarse crackles upon auscultation, and low oxygen saturation (89%). Providing supplemental oxygen is crucial to improve oxygenation and alleviate respiratory distress. Prompt intervention is necessary to prevent further complications and stabilize the patient's condition.

Choice C reason: Providing patient education on acute chest syndrome is important, but it is not the immediate priority in this emergency situation. Education can be given once the infant's acute symptoms are managed and stabilized. The focus should be on addressing the critical needs first, such as oxygenation and respiratory support.

Choice D reason: Giving a dose of morphine sulphate may help manage pain, but it is not the first priority in this scenario. The infant's respiratory status and oxygenation levels are more critical and require immediate attention. Pain management can be addressed after ensuring the infant's breathing and oxygen levels are stabilized.

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Correct Answer is D

Explanation

Choice A reason: Haemophilia patients often require Factor VIII replacement therapy before procedures such as dental cleanings to prevent bleeding. The statement that the child does not need Factor VIII before a dental cleaning indicates a misunderstanding of the need for prophylactic treatment.

Choice B reason: Aspirin is contraindicated for children with haemophilia as it can inhibit platelet function and increase the risk of bleeding. The statement that it is okay to use aspirin reflects a lack of understanding of the appropriate pain management for haemophilia.

Choice C reason: While it is important for children with haemophilia to stay active, certain high-impact or contact sports may increase the risk of bleeding and should be avoided. The statement that there are no limitations on the type of activities indicates a lack of awareness about the need to choose safe activities.

Choice D reason: Swimming is a low-impact activity that is generally safe and beneficial for children with haemophilia. It promotes cardiovascular fitness and muscle strength without putting undue stress on the joints or increasing the risk of bleeding. This statement demonstrates an understanding of appropriate activity choices for a child with haemophilia.

A. The primary care provider will discuss screening for diabetes today. B. You must fast tonight and return in the morning for a one-hour glucose test. C. The primary care provider will recommend that you eliminate sugar from your diet. D. The three-hour glucose tolerance test will be performed today.

Correct Answer is A

Explanation

Choice A reason: Discussing screening for diabetes is appropriate as pre-diabetes in a newly pregnant patient requires careful monitoring and management to prevent the development of gestational diabetes. Early detection and intervention can improve outcomes for both the mother and the baby.

Choice B reason: A one-hour glucose test is typically part of the gestational diabetes screening process, but it is not necessary to fast overnight specifically for the initial discussion and planning. The timing and preparation for specific tests will be guided by the healthcare provider.

Choice C reason: Eliminating sugar from the diet can be part of managing pre-diabetes, but it is not the immediate response to finding pre-diabetes in a newly pregnant patient. A more comprehensive approach will be discussed with the primary care provider.

Choice D reason: A three-hour glucose tolerance test is a diagnostic test for gestational diabetes, which may be recommended later if initial screening results warrant it. It is not typically performed immediately without prior discussion and planning with the healthcare provider.

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The nurse is providing care to an infant with sickle cell anaemia who has increased work of breathing, a fever, coarse crackles upon auscultation, oxygen saturation of 89%, and inconsolable crying. Which intervention will the nurse perform first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is providing education to the parent of an 8-year-old with haemophilia about ways to decrease the risk of a bleeding event. Which statement by the parent demonstrates that teaching was effective?

Correct Answer is D

Explanation

The nurse is performing an initial health history on a newly pregnant patient with "pre-diabetes." How will the nurse respond to this finding?

Correct Answer is A

Explanation

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