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 ["A","E"]
Explanation
Olanzapine is an antipsychotic drug that can cause weight gain and increased blood sugar as common side effects.
Therefore, the nurse should monitor the client’s weight and blood sugar regularly to prevent complications such as obesity and diabetes.
Choice B is wrong because olanzapine does not affect skin turgor, which is a measure of hydration status.
Choice C is wrong because olanzapine does not cause falls, although it may cause dizziness or unsteadiness as side effect.
Choice D is wrong because olanzapine does not cause significant changes in blood pressure, although it may cause orthostatic hypotension (a drop in blood pressure when standing up) as a side effect.
Correct Answer is B
Explanation
The nurse should make the statement “The client has hypoxemia after 10 minutes on a rebreather mask.” first. This is because SBAR (Situation- Background-Assessment-Recommendation) is a communication tool that helps provide essential, concise information, usually during crucial situations. The first component of SBAR is Situation, which is a concise statement of the problem.
The nurse should state the most urgent and relevant problem first, which is the client’s hypoxemia.
Choice A is wrong because it is not a clear statement of the situation.
It is vague and does not provide specific information about the client’s condition or vital signs.
It also expresses the nurse’s feeling rather than an objective assessment.
Choice C is wrong because it is part of the Assessment component of SBAR, not the Situation.
It provides numerical data about the client’s blood gas analysis, but it does not state the problem or the reason for calling the healthcare provider.
Choice D is wrong because it is part of the Background component of SBAR, not the Situation.
It provides pertinent and brief information related to the situation, such as the client’s medical history and diagnosis, but it does not state the current problem or concern.
Normal ranges for blood gas analysis are:
- PaO2: 80-100 mmHg
- PaCO2: 35-45 mmHg
- HCO3: 22-26 mEq/L
Hypoxemia is defined as a low level of oxygen in the blood, usually below 60 mmHg.
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