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 ["A","D"]
Explanation
A. Inwardly turned foot on the affected side.
This finding is consistent with DDH. In infants with DDH, the affected leg may appear shortened and rotated inwardly due to hip instability or dislocation.
B. Lengthened thigh on the affected side.
This finding is not typically associated with DDH. In fact, the affected thigh may appear shortened rather than lengthened due to abnormal positioning of the hip joint.
C. Absent plantar reflexes.
Absent plantar reflexes are not directly related to DDH. Plantar reflexes assess the function of the spinal nerves in the lower extremities and are not typically affected by hip dysplasia.
D. Asymmetric thigh folds.
This finding is consistent with DDH. Asymmetric thigh folds, where one thigh appears fuller or has more skin folds compared to the other, can be indicative of hip dysplasia. The skin folds may be more prominent on the unaffected side due to the displacement of the femoral head on the affected side.
Correct Answer is D
Explanation
A. Place the infant in prone position.
This option is incorrect. Placing the infant in the prone position (lying on the stomach) could put pressure on the spinal lesion, potentially causing discomfort or complications. It's important to minimize pressure on the affected area in infants with spina bifida.
B. Cover the infant's lesion with a dry cloth.
This option is incorrect. While keeping the lesion clean and dry is important for preventing infection, simply covering it with a dry cloth may not provide adequate protection. Proper wound care techniques, such as using sterile dressings and cleaning the area with prescribed solutions, are typically necessary to prevent infection and promote healing.
C. Feed the infant through an NG tube.
This option is incorrect. While infants with severe forms of spina bifida may have difficulty feeding due to associated complications, such as difficulty swallowing or weak sucking reflexes, feeding through a nasogastric (NG) tube is not a standard intervention for spina bifida itself. Feeding methods would depend on the specific needs and abilities of the infant, and may involve breastfeeding, bottle-feeding, or other methods under the guidance of healthcare professionals.
D. Diapering over a low defect will keep the infant free from infection.
This option is correct. Diapering over a low defect (the opening in the spine caused by spina bifida) helps to keep the area clean and reduce the risk of infection. By properly covering the defect with a diaper, exposure to urine and feces, which can increase the risk of infection, is minimized. Additionally, regular diaper changes and proper hygiene practices are essential for preventing complications in infants with spina bifida.
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