A 10-year old is admitted to the Emergency Room in a sickle cell crisis. Put the interventions in order by priority.
All options must be used.
Administer oxygen.
Start IV fluids.
Administer pain medication.
Draw lab work.
Correct Answer : A,B,C,D
A. Administer oxygen. This is the first priority because oxygen can help prevent further sickling of red blood cells and improve tissue perfusion.
B. Start IV fluids. This is the second priority because hydration can reduce blood viscosity and prevent vaso-occlusion.
C. Administer pain medication. This is the third priority because pain is a common and distressing symptom of sickle cell crisis and should be treated with opioids around the clock.
D. Draw lab work. This is the last priority because lab work can help monitor the severity of the crisis and the need for blood transfusions, but it does not directly relieve the patient’s symptoms or prevent complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
This is because gelatin is a low-fat dessert that contains only 0.1 grams of fat per cup.
It is also low in calories and can be flavored with fruit juice or fresh fruits for added nutrition.
Choice A is wrong because a slice of fruit pie contains about 14 grams of fat per slice, which is high for a low-fat diet.
Fruit pies also have added sugar and refined flour that can increase the calorie intake.
Choice C is wrong because a bran muffin contains about 9 grams of fat per muffin, which is also high for a low-fat diet.
Bran muffins may have some fiber benefits, but they also have added sugar and oil that can make them less healthy.
Choice D is wrong because one plain doughnut contains about 11 grams of fat per doughnut, which is also high for a low-fat diet.
Doughnuts are deep-fried and have a lot of sugar and refined flour that can contribute to weight gain and health problems.
Some other examples of low-fat dessert choices are sorbet, fruit salad, yogurt, pudding, and angel food cake.
These desserts are lower in fat and calories than pies, muffins, and doughnuts, and can satisfy a sweet tooth without compromising the dietary instructions.
Correct Answer is D
Explanation
A weak, rapid pulse indicates that the client is experiencing hypovolemia or low blood volume due to blood loss during surgery.
The nurse should recommend to the provider to administer intravenous fluids to restore the client’s circulating volume and improve their hemodynamic status.
Choice A is wrong because anticholinergics are drugs that block the action of acetylcholine, a neurotransmitter that stimulates the parasympathetic nervous system.
Anticholinergics can cause tachycardia, dry mouth, urinary retention, and blurred vision. They are not indicated for hypovolemia.
Choice B is wrong because urinary catheter placement is not a priority intervention for a client with hypovolemia.
Urinary catheterization can help monitor urine output and renal perfusion but does not address the underlying cause of low blood volume.
Choice C is wrong because beta blockers are drugs that block the action of epinephrine and norepinephrine, neurotransmitters that stimulate the sympathetic nervous system.
Beta-blockers can lower blood pressure, heart rate, and cardiac output.
They are not indicated for hypovolemia and can worsen the client’s condition.
To communicate this information using the SBAR tool, the nurse should follow these steps: Situation: Identify yourself, the client, and the problem.
For example: “I am (name), the nurse caring for (client name) in room (number).
I am calling because I am concerned that the client has developed hypovolemia after surgery.”
Background: Provide relevant and brief information related to the situation.
For example: “The client had a surgical procedure (name and type) at (time) today. They have lost (amount) of blood during and after surgery.
Their current vital signs are: blood pressure (value), pulse (value), respiratory rate (value), temperature (value), oxygen saturation (value).”
Assessment: Share your analysis and considerations of options. For
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