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.

Answer and Explanation

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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Correct Answer is A

Explanation

A. Changed mental status: This is a common indicator of a bladder infection in older adults, who may present with confusion or altered mental status instead of classic symptoms like dysuria or frequency.
B. WBC count 9,000/mm³ (5000 to 10,000/mm³): This WBC count is within the normal range and does not specifically indicate a bladder infection.
C. Diminished reflexes: This is not a typical indicator of a bladder infection and may suggest other neurological issues.
D. Temperature 37.3° C (99.1° F): This temperature is within the normal range and does not suggest an infection unless elevated or accompanied by other symptoms.

A. Close the doors to the room and to the bathroom. B. Assist the client to a nearby common area. C. Activate the fire alarm system. D. Use a fire extinguisher at the source of the smoke.

Correct Answer is B

Explanation

A. Close the doors to the room and to the bathroom: This helps to contain the smoke but does not address the immediate danger of the smoke.
B. Assist the client to a nearby common area: This is correct as ensuring the safety of the client is the top priority. The client should be moved to a safer location away from the smoke.
C. Activate the fire alarm system: This is important for alerting others to the fire but does not directly address the immediate danger to the client.
D. Use a fire extinguisher at the source of the smoke: This can be done after ensuring the client's safety, as the primary concern is to remove the client from potential harm.

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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?

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Naxlex Comprehensive Predictor Exams

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