A nurse is caring for a client who is experiencing a sickle cell crisis. During morning care, the assistive personnel alerts the nurse that the client is slurring their speech. Which of the following actions should the nurse take?

Assess the client's bilateral hand grasp strength.

Place a padded tongue blade at the client's bedside.

Check the client's bedside glucose level.

Administer flumazenil IV per facility policy to the client.

Answer and Explanation

The Correct Answer is A

A. Assess the client's bilateral hand grasp strength: Slurred speech in a client with sickle cell crisis raises concern for stroke due to vaso-occlusion in cerebral vessels. Assessing hand grasp strength helps evaluate for unilateral weakness, a key indicator of stroke, necessitating immediate intervention.

B. Place a padded tongue blade at the client's bedside: There is no indication the client is experiencing a seizure. Seizure precautions are not a priority unless additional neurological symptoms suggest seizure activity.

C. Check the client's bedside glucose level: Hypoglycemia can cause slurred speech, but in a client with sickle cell disease, stroke is a more likely cause. Assessing neurological function should take precedence over checking glucose unless the client has a history of diabetes or other risk factors.

D. Administer flumazenil IV per facility policy to the client: Flumazenil is used to reverse benzodiazepine overdose. There is no indication that the client has received benzodiazepines or is experiencing medication toxicity.

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Correct Answer is ["A","B","E"]

Explanation

A. Verify the solution with another RN prior to infusion: TPN is a high-risk therapy that requires verification by two RNs to ensure the correct formulation, preventing medication errors that could lead to severe complications.

B. Monitor serum blood glucose during infusion: TPN contains high concentrations of glucose, increasing the risk of hyperglycemia. Regular blood glucose monitoring helps detect imbalances and allows for timely intervention.

C. Increase the rate of infusion if administration is delayed: Increasing the infusion rate can lead to metabolic complications such as hyperglycemia and fluid overload. If TPN is delayed, the provider should be consulted for adjustments rather than increasing the rate independently.

D. Infuse 0.9% sodium chloride if the solution is not available: If TPN is unavailable, the correct alternative is an infusion of dextrose 10% in water (D10W) to prevent hypoglycemia, not 0.9% sodium chloride, which lacks glucose.

E. Obtain the client's weight daily: Daily weights help monitor fluid balance, nutritional status, and potential complications such as fluid retention or dehydration, ensuring proper TPN management.

A. Place pillows under the client's knees. B. Avoid use of anticoagulants. C. Discourage leg exercises while in bed. D. Apply compression stockings to the lower extremities.

Correct Answer is D

Explanation

A. Place pillows under the client's knees: Placing pillows under the knees can lead to venous stasis, increasing the risk of deep vein thrombosis (DVT). Prolonged knee flexion can also reduce circulation and contribute to joint stiffness. Instead, the client should be encouraged to keep their legs extended and change positions frequently to promote blood flow.

B. Avoid use of anticoagulants: Anticoagulants are commonly prescribed after surgery to prevent thromboembolic complications such as DVT and pulmonary embolism. Avoiding them may increase the client's risk of clot formation, especially if they have limited mobility. The decision to withhold anticoagulation should be based on specific contraindications rather than routine avoidance.

C. Discourage leg exercises while in bed: Leg exercises help prevent blood pooling in the lower extremities, reducing the risk of DVT. Discouraging movement can lead to complications such as impaired circulation, muscle stiffness, and clot formation. Encouraging active and passive range-of-motion exercises supports recovery and decreases the likelihood of postoperative complications.

D. Apply compression stockings to the lower extremities: Compression stockings help improve venous return and reduce the risk of clot formation by preventing blood from pooling in the lower extremities. They are particularly beneficial for clients with limited mobility after surgery. Using them in combination with early ambulation and anticoagulation therapy further decreases the risk of thromboembolic events.

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A nurse is caring for a client who is experiencing a sickle cell crisis. During morning care, the assistive personnel alerts the nurse that the client is slurring their speech. Which of the following actions should the nurse take?

Nursing Test Bank

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