A client is experiencing sickle cell crisis precipitated by a right lower lobe pneumonia. The vital signs are: HR-110/min: RR-28; B/P-96/54: T-100.8 PO: Pulse Oximetry-96%. What is the best nursing action?

Maintain IV fluid infusion and assess adequacy of hydration

Provide continuous sedation for pain relief

Insert an indwelling (Foley) catheter and monitor hourly urinary output

Prepare for endotracheal intubation and ventilatory support

Answer and Explanation

The Correct Answer is A

A) Maintain IV fluid infusion and assess adequacy of hydration: This is the best nursing action as adequate hydration is crucial in managing sickle cell crisis. It helps to reduce blood viscosity and prevent further sickling of red blood cells, which is especially important in the context of pneumonia, as dehydration can exacerbate the crisis.

B) Provide continuous sedation for pain relief: While managing pain is essential, continuous sedation is not the most appropriate first step in this situation. Pain management should be addressed, but hydration and treating the underlying causes (like pneumonia) take priority.

C) Insert an indwelling (Foley) catheter and monitor hourly urinary output: While monitoring urinary output can be important, it is not the most immediate action in this case. Focus should be on hydration and addressing the sickle cell crisis rather than on urinary output at this time.

D) Prepare for endotracheal intubation and ventilatory support: Although respiratory distress is a concern with pneumonia, the current pulse oximetry reading of 96% indicates adequate oxygenation at this time. Preparing for intubation should not be the first action unless the patient shows signs of respiratory failure or severe distress.

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Correct Answer is C

Explanation

A. "The chest pains caused by a spasm of my heart": This statement reflects a misunderstanding. Chronic stable angina is typically caused by myocardial ischemia due to atherosclerosis rather than spasms. While vasospasm can occur, it is not the primary cause of chronic stable angina.

B. "I should not experience chest pain since I am on aspirin therapy": This statement is misleading. Aspirin therapy helps reduce the risk of clot formation and subsequent heart attacks but does not eliminate angina. Patients may still experience angina symptoms during exertion or stress.

C. "I should hire someone to shovel snow in the winter": This statement indicates an understanding of the need to avoid excessive physical exertion that could trigger angina. Hiring someone to perform strenuous tasks like shoveling snow reflects a proactive approach to managing the condition and preventing potential angina episodes.

D. "Each time I have chest pain my heart is damaged more": This statement is overly alarmist. While recurrent angina can indicate underlying heart issues, occasional episodes of stable angina do not necessarily result in immediate, progressive heart damage.

A. Crackles heard at the lung bases B. Dorsalis pedis pulses +1 C. A pericardial friction rub D. Heart rate 50 beats per minute

Correct Answer is A

Explanation

A. Crackles heard at the lung bases: An S4 heart sound often indicates left ventricular hypertrophy or decreased compliance of the left ventricle, commonly seen in conditions like heart failure. Crackles in the lungs can suggest pulmonary congestion related to heart failure, making this the most relevant correlation.

B. Dorsalis pedis pulses +1: A weak pulse may indicate peripheral vascular issues, but it doesn't directly correlate with an S4 heart sound.

C. A pericardial friction rub: This is associated with pericarditis and not directly related to the S4 heart sound.

D. Heart rate 50 beats per minute: While bradycardia may be present in various cardiac conditions, it does not specifically correlate with the S4 sound, which is more about ventricular filling pressures.

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A client is experiencing sickle cell crisis precipitated by a right lower lobe pneumonia. The vital signs are: HR-110/min: RR-28; B/P-96/54: T-100.8 PO: Pulse Oximetry-96%. What is the best nursing action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who has chronic stable angina is being discharged. Which statement by the client indicates an understanding of the discharge teaching?

Correct Answer is C

Explanation

The nurse auscultates a S4 heart sound during the morning assessment of a client. Which additional assessment data would correlate with this finding?

Correct Answer is A

Explanation

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