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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

A sigmoidoscopy is a procedure used to examine the lower part of the colon (sigmoid colon and rectum). The knee-chest position allows for better visualization of the sigmoid colon by straightening the rectosigmoid junction.

Choice B rationale

The prone position is not typically used for sigmoidoscopy. This position does not provide optimal visualization of the sigmoid colon.

Choice C rationale

The orthopneic position, which involves sitting up and leaning forward, is not used for sigmoidoscopy.

Choice D rationale

The Trendelenburg position, which involves lying flat with the feet elevated higher than the head, is not used for sigmoidoscopy.

A. Change the dressing on the tracheostomy site. B. Suction the tracheostomy tube. C. Auscultate the client’s lungs. D. Clean the inner cannula.

Correct Answer is C

Explanation

A.Changing the dressing on the tracheostomy site is an important part of tracheostomy care, but it is not the first action that should be taken.

B.Suctioning the tracheostomy tube should only be performed if there are signs of airway obstruction (e.g., increased secretions, decreased oxygenation, or adventitious breath sounds). Suctioning too frequently or unnecessarily can cause mucosal damage and hypoxia.

C. Auscultating the lungs helps the nurse determine if there is increased secretions, diminished breath sounds, or other airway concerns that may require suctioning. This ensures that care is performed appropriately based on the client’s needs.

D.Cleaning the inner cannula is a necessary part of tracheostomy care, but it should bedone after assessing the airway and performing suctioning if needed.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing a patient for a sigmoidoscopy. In which of the following positions should the nurse place the patient?

Correct Answer is A

Explanation

A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse perform first when providing tracheostomy care?

Correct Answer is C

Explanation

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