A nurse is assisting with the plan of care for a patient who is experiencing sickle cell crises. What interventions should the nurse include in the plan of care?
Avoid administration of the influenza vaccine.
Provide a diet that is low in protein.
Decrease fluid intake to 1,500 mL daily.
Maintain the patient on bed rest.
The Correct Answer is D
Choice A rationale
Avoiding administration of the influenza vaccine is not a recommended intervention for a patient experiencing sickle cell crises. Vaccinations are important for patients with sickle cell disease to prevent infections that can trigger crises.
Choice B rationale
Providing a diet that is low in protein is not a recommended intervention for a patient experiencing sickle cell crises. Patients with sickle cell disease need a balanced diet that includes adequate protein to support tissue repair and growth.
Choice C rationale
Decreasing fluid intake to 1,500 mL daily is not a recommended intervention for a patient experiencing sickle cell crises. Adequate hydration is important to prevent sickling of cells and to maintain blood volume.
Choice D rationale
Maintaining the patient on bed rest is the correct intervention. Rest can help to decrease the body’s demand for oxygen, reduce stress on the body, and prevent complications such as acute chest syndrome.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
For a client with COPD who reports shortness of breath and little appetite, limiting fluid intake during meals can help to prevent early satiety and promote better food intake. Fluids can make the client feel full quickly, which can limit their intake of necessary nutrients.
Choice B rationale
Consuming three regular meals daily may not be the best approach for a client with COPD who has little appetite. Smaller, more frequent meals may be easier for the client to tolerate.
Choice C rationale
Eating lighter, low-calorie foods first is not the best advice for a client with COPD who has little appetite. The client may need high-calorie, nutrient-dense foods to meet their nutritional needs.
Choice D rationale
Eliminating dairy products is not generally recommended for clients with COPD unless they have a specific intolerance. Dairy products can be a good source of protein and other nutrients.
Correct Answer is B
Explanation
Choice A rationale
Wearing a surgical mask when entering the patient’s room is a standard precaution for all healthcare workers, but it may not be sufficient for a patient with severe coughing, night sweats, and blood in the sputum. These symptoms could indicate a contagious disease such as tuberculosis, which requires airborne precautions.
Choice B rationale
Placing the patient in a negative-pressure airflow room is the correct action. This type of room is used for patients who may have airborne infectious diseases. The negative pressure prevents airborne pathogens from escaping the room and infecting others.
Choice C rationale
Keeping a container for soiled linens outside the patient’s door is not the most appropriate action in this situation. While it is important to handle soiled linens properly to prevent the spread of infection, it does not address the potential airborne transmission of pathogens.
Choice D rationale
Remaining within 3 feet of the patient is not the most appropriate action in this situation. If the patient has an airborne infectious disease, healthcare workers should minimize close contact to prevent exposure.
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