A child is admitted to the hospital with a vaso-occlusive sickle cell crisis. Which prescription by the health care provider should the nurse implement first?
Ask the client about personal food preferences.
Determine what the client knows about this illness.
Obtain a urine specimen.
Administer pain relief medication.
The Correct Answer is D
Choice A rationale:
While addressing the client's food preferences is important for their overall care, pain management takes priority during a vaso-occlusive sickle cell crisis to alleviate suffering and prevent complications.
Choice B rationale:
Assessing the client's knowledge about the illness is significant for education, but pain relief should precede this assessment to promptly address their distress.
Choice C rationale:
Obtaining a urine specimen is a relevant diagnostic step, but pain management should be initiated before further assessments or interventions.
Choice D rationale:
Administering pain relief medication is the immediate nursing priority. Sickle cell crises are excruciating, and timely pain management helps alleviate suffering and improve the client's well-being.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Monitoring the stool consistency is a crucial nursing action to assess the effectiveness of pancreatic enzyme replacement therapy. Patients with pancreatic insufficiency, such as those with cystic fibrosis, may have difficulty digesting fats properly. Improved stool consistency, specifically a reduction in greasy and foul-smelling stools, indicates that the pancreatic enzymes are aiding in fat digestion.
Choice B rationale:
Pupillary reflex response assessment is unrelated to pancreatic enzyme replacement therapy. It is more commonly performed to assess neurological status or the effects of medications affecting the autonomic nervous system.
Choice C rationale:
Listening to breath sounds is important for assessing respiratory status, but it does not directly reflect the effectiveness of pancreatic enzyme replacement therapy.
Choice D rationale:
Auscultating the apical pulse rate is a general assessment of cardiovascular function and does not provide information about the effectiveness of pancreatic enzyme replacement therapy.
Correct Answer is D
Explanation
Choice A rationale:
Assessing the infant's ability to roll over is unrelated to the situation. The nurse's focus should be on safely retrieving the nasogastric tube without leaving the infant alone.
Choice B rationale:
Using a nesting pillow is not appropriate in this scenario. The nurse should prioritize getting the nasogastric tube rather than introducing unnecessary items into the crib.
Choice C rationale:
Putting the side rail all the way up might hinder the nurse's ability to access the counter and the nasogastric tube. It is not the most effective action in this situation.
Choice D rationale:
Calling for assistance ensures that the infant's safety is maintained while the nurse retrieves the nasogastric tube. Leaving the infant unattended increases the risk of harm, so involving someone else is the appropriate action.
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