A nurse is assisting with the plan of care for a client who is experiencing sickle cell crisis. Which of the following interventions should the nurse include in the plan of care?
Provide a diet that is low in protein.
Avoid administration of the influenza vaccine.
Maintain the client on bed rest.
Decrease fluid intake to 1,500 mL daily.
The Correct Answer is C
A. Provide a diet that is low in protein: This is incorrect because clients in sickle cell crisis require a well-balanced diet with adequate protein, along with increased fluid intake to help maintain hydration and reduce the risk of further complications.
B. Avoid administration of the influenza vaccine: This is incorrect because vaccination, including the influenza vaccine, is important for preventing infections that can exacerbate sickle cell crises.
C. Maintain the client on bed rest: This is correct because bed rest helps to reduce the energy expenditure and stress on the body, which can help manage pain and prevent further complications during a sickle cell crisis.
D. Decrease fluid intake to 1,500 mL daily: This is incorrect because increased fluid intake is crucial in sickle cell crisis to help prevent dehydration and promote proper blood flow, thereby reducing the risk of vaso-occlusive episodes.
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Related Questions
Correct Answer is C
Explanation
A. Elevate the head of the bed 45° before starting the CPM device: This is incorrect as elevating the head of the bed is not a necessary preparation for using the CPM device. The device should be used according to the specific postoperative guidelines.
B. Ensure the frame joint is in a flexed position before placing the leg onto the device: This is incorrect because the frame joint should generally be in an extended position to properly align the leg for movement through the device's range of motion.
C. Ensure the knee joint is positioned over the CPM device frame joint: This is correct because proper alignment of the knee joint with the CPM device's frame joint is crucial to ensure that the device functions correctly and promotes effective range-of-motion exercises.
D. Instruct the client to increase the degree of flexion as tolerated: This is incorrect because the degree of flexion should be adjusted according to the prescribed protocol by the healthcare provider and should not be self-adjusted by the client.
Correct Answer is B
Explanation
A. Ammonia 55 mcg/dL (10 to 80 mcg/dL): This value is within the normal range and does not indicate an immediate concern for a liver biopsy.
B. Platelets 60,000/mm³ (150,000 to 400,000/mm³): This value is significantly below the normal range and indicates thrombocytopenia, which increases the risk of bleeding during a liver biopsy and should be reported to the provider.
C. Aspartate aminotransferase 34 units/L (0 to 34 units/L): This value is on the upper limit of normal and generally does not require reporting unless there are other clinical concerns.
D. Bilirubin 1.0 mg/dL (0.3 to 1.0 mg/dL): This value is at the upper limit of normal and does not require reporting unless there are additional symptoms or concerns.
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