A nurse is caring for a client during a follow up visit at a gastrointestinal clinic.
Which of the following interventions should the nurse implement?
Select all that apply.
Assess peripheral circulation hourly.
Assess the client's mouth every 8 hr.
Use humidification with oxygen therapy. Administer IV fluids.
Raise the knee position on the client's bed.
Use an automated blood pressure cuff on the client's arm. Prepare for platelet transfusion.
Correct Answer : A,B,C
A. Assess peripheral circulation hourly. This is correct because clients with SCD are at risk of vaso-occlusive crisis, which can impair blood flow to the extremities and cause tissue ischemia and necrosis. The nurse should monitor for signs of poor circulation such as pallor, coolness, numbness, or pain.
B. Assess the client's mouth every 8 hr. This is correct because clients with SCD are prone to oral ulcers, infections, and dental problems due to chronic anemia and reduced oxygen delivery to the oral mucosa. The nurse should inspect the mouth for lesions, bleeding, inflammation, or infection and provide oral hygiene as needed.
C. Use humidification with oxygen therapy. Administer IV fluids. This is correct because clients with SCD need adequate hydration and oxygenation to prevent sickling of red blood cells and further complications. Humidification helps moisten the airways and prevent dehydration of the mucous membranes. IV fluids help maintain fluid and electrolyte balance and reduce blood viscosity.
D. Raise the knee position on the client's bed. This is incorrect because this can impede venous return and worsen peripheral circulation. The nurse should keep the client's extremities in a neutral position and avoid tight or restrictive clothing or devices.
E. Use an automated blood pressure cuff on the client's arm. Prepare for platelet transfusion. This is incorrect because this can cause mechanical trauma to the arm and trigger a vasoocclusive crisis. The nurse should use a manual blood pressure cuff and avoid applying pressure to the arm. Platelet transfusion is not indicated for clients with SCD unless they have thrombocytopenia or bleeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Using isopropyl alcohol to clean hearing aids is not recommended. Isopropyl alcohol can damage the hearing aid components, especially the plastic parts. It is essential to use cleaning solutions specifically designed for hearing aids to avoid damaging them. Including this statement indicates a misunderstanding of proper hearing aid care.
Choice B rationale:
Replacing the batteries every 2 weeks is a standard recommendation for hearing aid users. Hearing aid batteries typically last 1 to 2 weeks, depending on usage. Regular battery replacement ensures the hearing aids continue to function optimally. This statement demonstrates an understanding of the basic care required for behind-the-ear hearing aids.
Choice C rationale:
Cleaning the ear with cotton swabs before inserting hearing aids is not advisable. Cotton swabs can push earwax further into the ear canal, leading to impaction. Excessive earwax can interfere with hearing aid function. Instead, clients should be encouraged to clean the outer parts of the hearing aids and avoid inserting any objects, including cotton swabs, into the ear canal.
Choice D rationale:
Disconnecting the battery when removing hearing aids is the correct practice. By disconnecting the battery, the client ensures that the hearing aids are turned off, preserving battery life and preventing unnecessary drainage. This statement indicates an understanding of proper hearing aid care and demonstrates the client's ability to maintain the device effectively.
Correct Answer is C
Explanation
Choice A rationale:
Instructing the client to maintain a full bladder is not relevant to an amniocentesis procedure. A full bladder may be necessary for certain other procedures, such as a pelvic ultrasound, but not for amniocentesis.
Choice B rationale:
Administering a tocolytic 30 minutes before the procedure is not a standard practice for amniocentesis. Tocolytics are medications used to suppress uterine contractions and are not routinely administered before this procedure.
Choice C rationale:
Monitoring the fetal heart rate throughout the procedure is essential during an amniocentesis. This helps assess the well-being of the fetus and ensures that the procedure is not causing fetal distress. Any changes in fetal heart rate can indicate potential complications and may require immediate intervention.
Choice D rationale:
Placing the client in Trendelenburg position during the procedure is not recommended for amniocentesis. Trendelenburg position, where the body is supine with the legs elevated higher than the head, is not routinely used during this procedure and may cause discomfort to the client without providing significant clinical benefits.
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