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:
This statement reflects an accurate understanding of varicella (chickenpox) transmission and infection control. The lesions of varicella contain the virus and are contagious until they have crusted over. Allowing the child to go to the playroom only after the lesions have crusted helps prevent the spread of the virus to other individuals.
Choice B rationale:
This statement is incorrect because waiting for the crusts to fall off the lesions before bathing the child is not necessary. In fact, keeping the lesions clean and maintaining proper hygiene through gentle bathing can help prevent secondary bacterial infections.
Choice C rationale:
This statement is incorrect because bedrest for 3 days is not necessary for a child with varicella. While it's important to minimize contact with others during the contagious phase, physical activity can be gradually resumed as long as the lesions have crusted to prevent transmission.
Choice D rationale:
This statement is incorrect. Once a person has had chickenpox (varicella), they develop immunity to the virus and do not need to wear a mask when visiting someone with active varicella. This is because they are already immune to the virus due to their prior infection.
Correct Answer is B
Explanation
Choice A rationale:
Implementing fluid restrictions is not recommended for a child with diabetic ketoacidosis (DKA). DKA is characterized by dehydration and electrolyte imbalances, and fluid replacement is a crucial aspect of its management. Restricting fluids could worsen dehydration and hinder the correction of metabolic imbalances.
Choice B rationale:
(Correct Choice) Monitoring vital signs every 8 hours is an important intervention for a school-age child with DKA. Vital signs, including heart rate, respiratory rate, blood pressure, and temperature, provide valuable information about the child's overall condition, fluid status, and response to treatment. More frequent monitoring might be necessary during the acute phase of DKA.
Choice C rationale:
Initiating continuous cardiac monitoring is not typically indicated for a school-age child with DKA. While DKA can have effects on the cardiovascular system, continuous cardiac monitoring is reserved for more critical situations where immediate changes in heart rhythm need to be detected.
Choice D rationale:
Administering subcutaneous insulin 30 minutes before meals is not appropriate for a child with DKA. In DKA management, insulin is typically administered intravenously to achieve more precise control over blood glucose levels. Subcutaneous insulin might not provide the rapid and consistent action needed to address the acute hyperglycemia and metabolic acidosis in DKA.
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