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 D

Explanation

A. Wear a simple face mask when caring for the client: This is incorrect because pertussis is highly contagious and requires more stringent precautions, such as an N95 mask, to prevent transmission.
B. Wear a gown when caring for the client: This is incorrect as wearing a gown is not typically required for pertussis unless there is a risk of direct contact with respiratory secretions.
C. Place the client in a negative air pressure room: This is incorrect because pertussis does not require negative air pressure; it is transmitted through droplets, not airborne particles.
D. Wear an N95 mask when in the client's room: This is correct because an N95 mask provides the necessary protection against respiratory droplets that can transmit pertussis, ensuring proper protection for healthcare workers.

A. Place the client in a negative-pressure airflow room. B. Wear a surgical mask when entering the client's room. C. Have a container for soiled linens outside the client's door. D. Remain within 91.4 cm (3 ft) of the client.

Correct Answer is A

Explanation

A. Place the client in a negative-pressure airflow room: This is correct as these symptoms are indicative of tuberculosis (TB), which requires airborne precautions. A negative-pressure room helps to prevent the spread of airborne pathogens.
B. Wear a surgical mask when entering the client's room: This is incorrect because a surgical mask does not provide adequate protection against airborne particles; an N95 respirator is necessary for airborne precautions.
C. Have a container for soiled linens outside the client's door: This is incorrect as soiled linens should be handled and disposed of within the room under appropriate infection control protocols, not just placed outside.
D. Remain within 91.4 cm (3 ft) of the client: This is incorrect as maintaining this distance does not prevent the spread of airborne diseases. Proper airborne precautions, including the use of personal protective equipment, are necessary.

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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?

Nursing Test Bank

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