A 16-year-old is admitted with sickle cell crisis. The patient has a pain scale rating of 10 and the following vital signs: HR 115, BP 120/82, RR 18, oxygen saturation 91%, temperature 101.4°F. Select all the appropriate nursing interventions for this patient at this time?
Remove restrictive clothing or objects from the patient
Administer IV Morphine per MD order
Administer oxygen per MD order
Place on NPO
Start intravenous fluids per MD order
Keep patient on bed rest
Correct Answer : A,B,C,D,E,F
A. Remove restrictive clothing or objects from the patient: This helps to promote comfort and improve circulation.
B. Administer IV Morphine per MD order: Morphine is a common medication used to manage severe pain associated with sickle cell crisis.
C. Administer oxygen per MD order: Oxygen may be needed to improve oxygen saturation and support respiratory function, especially if the patient is hypoxic.
D. Place on NPO: This is appropriate in case the patient needs any procedures or interventions that require fasting.
E. Start intravenous fluids per MD order: Intravenous fluids help to hydrate the patient and improve blood flow, which can help alleviate symptoms of sickle cell crisis.
F. Keep patient on bed rest: Bed rest is important to conserve energy and minimize the risk of further complications during a sickle cell crisis.
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Related Questions
Correct Answer is D
Explanation
A. Multiple hospitalizations for COPD are not a direct contraindication for HRT, although respiratory health should be monitored.
B. Concurrent treatment for GERD is not a contraindication for HRT.
C. History of dermatitis does not contraindicate the use of HRT.
D. History of breast cancer is a significant contraindication for HRT due to the potential for hormone therapy to stimulate the growth of hormone-sensitive cancer cells.
Correct Answer is A
Explanation
A. Inadequate production of platelets results in an increased risk of bleeding, making the client vulnerable to injury. Therefore, the priority nursing diagnosis is "Risk for Injury related to increased bleeding tendency."
B. Decreased antibody production is not directly related to inadequate platelet production.
C. While decreased platelet production may contribute to hypovolemia in some cases, the primary concern is the risk of bleeding rather than decreased cardiac output.
D. Impaired gas exchange is not directly related to inadequate platelet production.
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