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. Neutrophils 57%: This value reflects the percentage of neutrophils in the white blood cell count and does not specifically indicate the effectiveness of iron therapy. It is more related to the body’s immune response.

B. International Normalized Ratio (INR) 13 seconds: INR is a measure of blood coagulation and is not directly related to iron levels or the treatment of anemia. Therefore, this result does not indicate the success of ferrous sulfate therapy.

C. Total reticulocyte count 2.2% of total RBC count: An increased reticulocyte count indicates that the bone marrow is producing more red blood cells, which is a positive response to iron supplementation. A reticulocyte count around this percentage suggests an appropriate response to therapy for iron deficiency anemia.

D. Platelet count 250,000/µL: This is a normal platelet count and does not provide information specific to the effectiveness of iron therapy. It does not reflect the state of anemia or the response to iron supplementation.

A. Monitor serum sodium levels B. Auscultate breath sounds C. Perform daily weights D. Take the blood pressure

Correct Answer is C

Explanation

A. Monitor serum sodium levels: While serum sodium levels can provide some information about fluid balance, they are not the most direct indicator of the effectiveness of furosemide
in reducing peripheral edema.

B. Auscultate breath sounds: This is important for monitoring potential fluid overload or pulmonary complications, but it does not directly assess the reduction of peripheral edema, which is the primary concern with furosemide administration.

C. Perform daily weights: This method is the best way to evaluate the client's response to furosemide. Daily weights can provide a clear indication of fluid status and changes in peripheral edema, as a decrease in weight typically reflects effective diuresis.
D. Take the blood pressure: While monitoring blood pressure is important, especially in clients receiving diuretics, it does not specifically measure the effectiveness of the medication in addressing peripheral edema.

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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 has recently started ferrous sulfate 500 mg by mouth two times per day for anemia. Which of the following data would indicate to the nurse that the therapy is successful?

Correct Answer is C

Explanation

The nurse is administering Furosemide 40 mg PO to a client with peripheral edema. Which method should the nurse use to best evaluate the client's response to this medication?

Correct Answer is C

Explanation

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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?