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 C
Explanation
The correct answer is choice C. 6.8 to 7.7 kg (15 to 17 lb).
Choice A rationale:
This weight range is above the average for a 6-month-old infant. According to growth charts, the 50th percentile weight for a 6-month-old male is approximately 7.9 kg (17 lb 8 oz), and for a female, it’s about 7.3 kg (16 lb 1 oz). Therefore, 8.6 to 9.5 kg would be considered above average and not the anticipated weight for most infants.
Choice B rationale:
This weight range is below the average for a 6-month-old infant. The average weight at 6 months is significantly higher than 4.1 to 5 kg, as infants are expected to double their birth weight by 5 months of age. Therefore, an infant weighing between 9 to 11 lb at 6 months would be considered underweight.
Choice C rationale:
This weight range is within the average for a 6-month-old infant. As mentioned, the 50th percentile weights for 6-month-old infants are approximately 7.9 kg for males and 7.3 kg for females. This choice falls within the expected weight gain trajectory where an infant is anticipated to double their birth weight by 5 months and then gain an additional pound or so by 6 months.
Choice D rationale:
This weight range is significantly above the average for a 6-month-old infant. It is well above the 95th percentile for this age group and would be considered unusual without underlying health conditions that could contribute to such a weight at this age. An infant weighing between 23 to 25 lb at 6 months would be exceptionally rare and likely indicative of an abnormal growth pattern.
Correct Answer is D
Explanation
The correct answer is Choice D.
Choice A rationale: Administering an oral corticosteroid is not the first action the nurse should take. Corticosteroids are used to reduce inflammation and itching caused by poison ivy. However, they are usually prescribed if the symptoms are severe or if the rash covers a large area of the body. It’s important to note that corticosteroids can have side effects, especially when used for a long time, so they should be used under the supervision of a healthcare provider.
Choice B rationale: Applying calamine lotion to the affected area can help soothe the skin and relieve itching caused by poison ivy. However, this is not the first action the nurse should take. The first step is to remove the oil from the skin that causes the allergic reaction. Calamine lotion can be applied after the area has been thoroughly washed.
Choice C rationale: Instructing the parent to give the child an oatmeal bath twice daily can help soothe the skin and relieve itching. However, this is not the first action the nurse should take. Similar to calamine lotion, an oatmeal bath can be beneficial after the area has been thoroughly washed to remove the oil from the skin.
Choice D rationale: The first action the nurse should take when caring for a child exposed to poison ivy is to flush the area with cold, running water. This helps to remove the oil (urushiol) from the skin that causes the allergic reaction. It’s important to do this as soon as possible after exposure to help prevent the spread of the oil to other areas of the body or to other people. After flushing the area, the nurse can then apply calamine lotion or recommend an oatmeal bath to help soothe the skin and relieve itching.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.