A nurse is contributing to the plan of care for an adolescent client who has sickle cell anemia and is experiencing a vaso-occlusive crisis. Which of the following interventions should the nurse include in the plan?
Decrease daily oral fluid intake.
Maintain bed rest to prevent hypoxemia.
Apply cold compresses to painful joints.
Administer meperidine to eliminate a fever.
The Correct Answer is B
Choice A rationale:
Decrease daily oral fluid intake. Rationale: This choice is not appropriate for a client experiencing a vaso-occlusive crisis in sickle cell anemia. In this crisis, there is a risk of dehydration due to increased fluid loss, and decreasing oral fluid intake would exacerbate this issue. Adequate hydration is important to prevent further sickling of red blood cells and maintain organ perfusion.
Choice B rationale:
Maintain bed rest to prevent hypoxemia. Rationale: This is the correct choice. During a vaso-occlusive crisis in sickle cell anemia, blood flow to certain tissues is restricted, leading to tissue hypoxia and pain. Bed rest is recommended to reduce metabolic demands and oxygen consumption, helping to prevent further tissue damage and improve oxygenation. It also reduces the risk of complications such as thrombosis and respiratory compromise.
Choice C rationale:
Apply cold compresses to painful joints. Rationale: Applying cold compresses is not a recommended intervention for vaso-occlusive crisis in sickle cell anemia. Cold can exacerbate vasoconstriction and further compromise blood flow to the affected tissues. Warm compresses or warm baths might be more appropriate to promote vasodilation and alleviate pain.
Choice D rationale:
Administer meperidine to eliminate a fever. Rationale: Administering meperidine solely to eliminate a fever is not the primary focus of care for a vaso-occlusive crisis. The priority is to manage pain and improve tissue perfusion. Meperidine is an opioid analgesic that can be used to manage severe pain associated with sickle cell crises, but it should be given with caution due to the risk of respiratory depression and the potential for addiction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Obtain the specimen by swabbing the infant's rectum using a sterile culture swab. This is the correct choice. When collecting a stool specimen from an infant, the rectal swab method is commonly used. A sterile culture swab helps prevent contamination and ensures accurate results for detecting the presence of ova and parasites in the stool.
Choice B rationale:
Place a urine collection device on the infant until the specimen is obtained. This choice is not appropriate for collecting a stool specimen. A urine collection device is used for collecting urine, not stool. The specimen for ova and parasites needs to be taken directly from the rectum or diaper to accurately identify any infestations.
Choice C rationale:
Transfer the specimen to the collection container using povidone-iodine-soaked gauze. While povidone-iodine is an antiseptic, it is not typically used to transfer stool specimens. Using a sterile swab or a clean, dry container is more suitable for collecting and transporting stool samples to the lab.
Choice D rationale:
Maintain the specimen at room temperature after collection until it is transferred to the lab. Stool specimens for ova and parasites usually require refrigeration to prevent the degradation and growth of potential pathogens. Room temperature might lead to the overgrowth of bacteria and parasites, affecting the accuracy of test results.
Correct Answer is B
Explanation
Choice A rationale:
Administer pain medication. Administering pain medication is important for the preschooler's comfort, but it is not the nurse's priority action in this scenario. The priority is to ensure adequate circulation to the extremities, which can be assessed by checking capillary refill.
Choice B rationale:
Check capillary refill. This is the correct answer because the nurse's priority is to assess the child's circulation and tissue perfusion. In 90-90 traction, there is a risk of impaired circulation to the extremities due to the positioning. Checking capillary refill provides information about the adequacy of blood flow to the capillaries and is crucial for early detection of any circulation problems.
Choice C rationale:
Cleanse and dress the pin sites. While caring for the pin sites is important to prevent infection, it is not the priority action at this moment. Ensuring proper circulation and perfusion takes precedence over pin site care.
Choice D rationale:
Reposition the child every 2 hr. Repositioning the child is important to prevent complications associated with immobility, but it is not the nurse's priority action in this situation. The primary concern is to assess and address any circulation issues.
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