A nurse is caring for an adolescent who is having a sickle cell crisis. Which of the following nursing actions should the nurse take?
withhold opioids to avoid dependence
Assist RN with administering a blood transfusion
Initiate a 2 L/day fluid restriction
Encourage exercise
The Correct Answer is B
A. Withhold opioids to avoid dependence.
This option is incorrect. Opioid analgesics are commonly used to manage the severe pain associated with sickle cell crisis. Withholding opioids during a crisis could lead to inadequate pain relief and compromise the adolescent's comfort and recovery. It's important to appropriately administer opioids as prescribed to alleviate pain and suffering.
B. Assist RN with administering a blood transfusion.
This option may be appropriate depending on the severity and indications of the sickle cell crisis. Blood transfusions are sometimes used to treat sickle cell crises, particularly in cases of severe anemia or acute complications such as acute chest syndrome. However, the decision to administer a blood transfusion should be made by the healthcare provider based on the individual patient's clinical status and needs. The nurse's role would include assisting the registered nurse (RN) with the administration of the transfusion and monitoring the adolescent for any adverse reactions.
C. Initiate a 2 L/day fluid restriction.
This option is incorrect. During a sickle cell crisis, it is important to maintain adequate hydration to help prevent dehydration and reduce the viscosity of blood, which can help prevent sickling of red blood cells. Fluid intake should be encouraged, and there is typically no need for fluid restriction unless there are specific medical reasons to do so.
D. Encourage exercise.
This option is incorrect. During a sickle cell crisis, the adolescent is likely experiencing significant pain and discomfort, which may limit their ability to engage in physical activity. Encouraging exercise during a crisis could exacerbate pain and potentially lead to complications. Rest and minimizing physical exertion are typically recommended during a sickle cell crisis to promote comfort and conserve energy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
To calculate the appropriate dose of Theophylline for the child weighing 4.69 kg:
Dose = Weight (kg) × Dose (mg/kg)
Dose = 4.69 kg × 4 mg/kg
Dose = 18.76 mg
So, the appropriate dose is approximately 18.7 mg.
Correct Answer is B
Explanation
A. Drooling:
Drooling can occur post-tonsillectomy due to throat discomfort or swelling. However, it is not specific to hemorrhage. It may result from pain, swelling, or difficulty swallowing.
B. Continuous swallowing:
Continuous swallowing is indeed a clinical manifestation of hemorrhage after a tonsillectomy. The presence of blood in the throat triggers the swallowing reflex, leading to frequent swallowing by the patient. This symptom is characteristic of hemorrhage and requires immediate medical attention.
C. Poor fluid intake:
Poor fluid intake can occur post-tonsillectomy due to pain, discomfort, or nausea. While it can be a concern for overall recovery, it is not specific to hemorrhage.
D. Increased pain:
Increased pain can be associated with hemorrhage, especially if it is sudden, severe, or worsening. However, it is not as specific as continuous swallowing in indicating hemorrhage post-tonsillectomy. Increased pain can also be due to various other reasons such as inflammation, infection, or trauma.
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