A client with sickle cell disease is in a vaso-occlusive crisis and reporting a severe headache with blurry vision.
What intervention should the nurse perform first?
Administer analgesic medication.
Assess the client's neurological status.
Increase the client's intravenous fluids.
Administer 2 L of oxygen via nasal cannula.
The Correct Answer is B
Choice A rationale
While administering analgesics is a crucial step in managing a vaso-occlusive crisis due to severe pain, it is not the first intervention. The client's report of a severe headache with blurry vision, particularly in the context of sickle cell disease, is a sentinel symptom. These neurological signs can indicate a central nervous system complication, such as a stroke, which requires immediate neurological assessment before any other interventions.
Choice B rationale
In a vaso-occlusive crisis, a severe headache and blurry vision are neurological red flags. These symptoms suggest potential cerebral hypoxia or infarction, which could be a prelude to a stroke. Assessing the client's neurological status is the first priority to establish a baseline and determine the extent of the neurological deficit. This rapid assessment guides subsequent life-saving interventions.
Choice C rationale
Increasing intravenous fluids is a standard component of vaso-occlusive crisis management to promote hemodilution and improve blood flow. However, it is not the first action in this specific scenario. The client's presenting symptoms of headache and blurry vision point to a potential neurological emergency that requires immediate assessment to rule out or confirm a stroke, which takes precedence over general fluid management.
Choice D rationale
Administering oxygen is beneficial in a vaso-occlusive crisis to address tissue hypoxia. However, it is not the immediate first action given the client's specific neurological symptoms. Oxygen saturation is typically maintained above 95% in these patients. The priority is to assess the client's neurological status to rapidly identify a potentially life-threatening stroke, which dictates the immediate course of action.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The mother is O- and the newborn is A+, which creates a risk for Rh incompatibility. The mother's body has been exposed to the Rh-positive antigens from the newborn, potentially leading to the development of anti-Rh antibodies. To prevent the mother's immune system from developing these antibodies, which could affect a future Rh-positive pregnancy, a Rho (D) Immune Globulin injection must be administered. This injection needs to be given within 72 hours of delivery.
Choice B rationale
It is incorrect to educate the client that they do not require Rho (D) Immune Globulin. The Rh incompatibility between an Rh-negative mother and an Rh-positive newborn is the exact situation where Rho (D) Immune Globulin is indicated. The purpose of the injection is to prevent the maternal immune system from recognizing the Rh-positive fetal cells, thereby preventing the production of antibodies that could harm a subsequent pregnancy.
Choice C rationale
Advising the client to wait until their physician's appointment at the end of the week is inappropriate. Rho (D) Immune Globulin must be administered within 72 hours of delivery to be effective in preventing the sensitization of the mother's immune system. Delaying the injection beyond this window significantly reduces its effectiveness. Therefore, the injection must be given before the client is discharged from the hospital.
Choice D rationale
Informing the physician that the injection cannot be given due to the client being discharged is an inappropriate action. It is the nurse's responsibility to ensure that the client receives all necessary postpartum care before discharge. The Rho (D) Immune Globulin injection is a critical part of postpartum care for an Rh-negative mother with an Rh-positive newborn and must be administered within the hospital stay to ensure timely intervention
Correct Answer is D
Explanation
Choice A rationale
Measuring blood pressure hourly is an important part of monitoring a postpartum client, but it is not the priority. While vital signs are crucial, the immediate physiological threat is ongoing hemorrhage from uterine atony, which must be addressed directly to prevent shock.
Choice B rationale
Preparing to administer blood products may become necessary if the client experiences significant blood loss, but it is not the initial priority. The first intervention is to stop or reduce the bleeding by promoting uterine contraction, which will minimize the need for subsequent blood transfusions.
Choice C rationale
Administering intravenous fluids is a supportive measure to maintain circulatory volume, but it does not address the underlying cause of the hemorrhage. The priority is to stimulate uterine contractions to compress the myometrial arteries and prevent further blood loss.
Choice D rationale
Initiating an oxytocin infusion is the priority nursing intervention. Oxytocin is a potent uterotonic agent that stimulates uterine contractions, causing the myometrium to clamp down on blood vessels at the placental site, thereby reducing postpartum hemorrhage.
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