A nurse in an emergency department is caring for a client who is in a sickle cell crisis. Which of the following actions should the nurse take?(Select all that apply.).
Administer oxygen.
Administer opioids.
Administer whole blood.
Elevate the head of the bed to 30°.
Keep the client NPO.
Correct Answer : A,B,D
Choice A rationale:
The nurse should administer oxygen to the client experiencing a sickle cell crisis. Sickle cell crisis can cause vaso-occlusion, leading to tissue hypoxia and pain. Administering oxygen helps to improve tissue oxygenation and relieve symptoms.
Choice B rationale:
Administering opioids is appropriate for managing the severe pain associated with a sickle cell crisis. Opioids are effective analgesics that can help alleviate the acute pain experienced by the client.
Choice C rationale:
Administering whole blood is not typically indicated for a sickle cell crisis. Whole blood transfusion is reserved for specific indications, such as severe anemia or acute blood loss, but it is not a standard treatment for sickle cell crisis pain.
Choice D rationale:
Elevating the head of the bed to 30° can improve oxygenation and reduce the workload on the respiratory system, which is beneficial for clients experiencing a sickle cell crisis. It helps to optimize lung expansion and alleviate hypoxia.
Choice E rationale:
Keeping the client NPO (nothing by mouth) is not necessary in a sickle cell crisis. There is no indication that the client cannot tolerate oral intake, so allowing them to eat and drink as usual is appropriate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
The nurse should not advise the client with multiple sclerosis to schedule all physical activities for the morning hours. While some individuals with multiple sclerosis may experience increased fatigue later in the day, the best approach is to encourage the client to schedule activities at times when they feel the most energetic and to balance physical activity with rest throughout the day.
Choice B rationale:
Monitoring blood pressure is essential while taking fingolimod, a medication used to treat multiple sclerosis, as it can cause a transient decrease in heart rate and blood pressure.
Therefore, the nurse should include this statement in the teaching to ensure the client's safety and early detection of any issues.
Choice C rationale:
This is the correct statement to include in the teaching. Clients with multiple sclerosis should avoid rigorous activities that increase body temperature, as this can worsen their symptoms due to the sensitivity of demyelinated nerves to heat. Activities such as hot baths or engaging in strenuous exercise in hot weather should be avoided.
Choice D rationale:
Corticosteroids are not typically used as a long-term treatment for multiple sclerosis. Instead, they are used for short courses during exacerbations to reduce inflammation and manage acute symptoms. Long-term use of corticosteroids can lead to significant adverse effects, so the nurse should not include this statement in the teaching.
Correct Answer is D
Explanation
Choice A rationale:
A PaO2 value of 86 mm Hg is within the normal range (80-100 mm Hg) and does not indicate respiratory acidosis. PaO2 measures the partial pressure of oxygen in arterial blood.
Choice B rationale:
A pH of 7.4 is within the normal range (7.35-7.45) and does not indicate respiratory acidosis. The pH reflects the acidity or alkalinity of the blood.
Choice C rationale:
An HCO3 (bicarbonate) level of 16 mEq/L is within the normal range (22-28 mEq/L) and does not indicate respiratory acidosis. HCO3 is a measure of the metabolic component of the body's acid-base balance.
Choice D rationale:
This is the correct choice. A PaCO2 value of 58 mm Hg is elevated and indicates respiratory acidosis. PaCO2 measures the partial pressure of carbon dioxide in arterial blood, and an elevated value suggests the presence of excess carbon dioxide, leading to acidosis.
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