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 C
Explanation
This would help the client to feel valued, respected and involved in their own care, which can enhance their self-esteem.
Choice A is wrong because adding a nursing diagnosis of lowered self-esteem to the care plan does not address the underlying causes of the problem or provide any interventions to improve it.
It may also label the client and make them feel worse.
Choice B is wrong because giving praise for every decision the client makes is not realistic or sincere.
It may also undermine the client’s confidence and autonomy by implying that they need constant approval from others.
Choice D is wrong because modeling competent care for the client does not necessarily help them to maintain their self-esteem.
It may even make them feel inadequate or dependent on the nurse.
Correct Answer is A
Explanation
A toileting routine is the priority intervention for a client diagnosed with total urinary incontinence because it helps to prevent skin breakdown, infection, and odor. It also promotes dignity and comfort for the client.
Choice B. Kegel exercises are wrong because they are not effective for total urinary incontinence, which is the complete loss of bladder control. Kegel exercises are more useful for stress or urge urinary incontinence, which are caused by weak pelvic floor muscles.
Choice C. Surgery is wrong because it is not a priority intervention for total urinary incontinence.
Surgery may be considered a last resort option if other conservative measures fail to improve the condition. Surgery may also have risks and complications that need to be weighed against the benefits.
Choice D. Anticholinergic drug therapy is wrong because it is not a priority intervention for total urinary incontinence.
Anticholinergic drugs are used to treat overactive bladder or urge urinary incontinence, which are caused by involuntary bladder contractions. Anticholinergic drugs may have side effects such as dry mouth, constipation, blurred vision, and confusion.
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