A nurse is planning care for a patient who has been admitted due to severe coughing, night sweats, and blood in the sputum.
What precautions should the nurse take?

Choice A rationale: The abdominal findings require follow-up. The client reports mild abdominal pain, rating it as 7 on a scale of 0 to 10, and states they haven’t had a bowel movement in 4 days. Additionally, the physical exam reveals tenderness to palpation and high-pitched bowel sounds in the gastrointestinal area. The CT scan indicates an obstruction in the small intestine, as evidenced by distention with fluid and gas in the small intestine and the absence of gas in the colon. These symptoms suggest a significant gastrointestinal issue that needs further evaluation and management.

Choice B rationale: The BUN level also requires follow-up. The BUN level is elevated at 25 mg/dL, which is above the normal range of 10 to 20 mg/dL. This could indicate dehydration or kidney dysfunction, especially in the context of the client’s symptoms and dry mucous membranes. Elevated BUN levels can be caused by a high-protein diet, dehydration, certain medications, and a variety of medical conditions, including kidney disease.

Choice C rationale: The blood pressure requires follow-up. The client’s blood pressure is low at 92/60 mm Hg. This, combined with an elevated pulse of 106/min, could indicate hypovolemia or dehydration, especially given the client’s vomiting and lack of bowel movements. Hypovolemia refers to a decrease in the volume of blood in the body, which can be caused by a variety of conditions, including dehydration, severe burns, and excessive sweating. Hypovolemia can lead to hypotension (low blood pressure).

Choice D rationale: The breath sounds do not require follow-up. The respiratory examination reveals bilateral breath sounds clear, which is within the normal range. Clear breath sounds indicate that air is flowing smoothly through the bronchial tubes and lungs without obstruction, which is a positive sign.

Choice E rationale: The WBC count does not require follow-up. The WBC count is 9,000/mm, which is within the normal range of 5,000 to

Choice F rationale. Potassium level: The potassium level is low at 3.3 mEq/L (normal range: 3.5 to 5 mEq/L), which can be concerning and may need correction to prevent complications such as cardiac arrhythmias.

Choice A rationale

Avoiding administration of the influenza vaccine is not a recommended intervention for a patient experiencing sickle cell crises. Vaccinations are important for patients with sickle cell disease to prevent infections that can trigger crises.

Choice B rationale

Providing a diet that is low in protein is not a recommended intervention for a patient experiencing sickle cell crises. Patients with sickle cell disease need a balanced diet that includes adequate protein to support tissue repair and growth.

Choice C rationale

Decreasing fluid intake to 1,500 mL daily is not a recommended intervention for a patient experiencing sickle cell crises. Adequate hydration is important to prevent sickling of cells and to maintain blood volume.

Choice D rationale

Maintaining the patient on bed rest is the correct intervention. Rest can help to decrease the body’s demand for oxygen, reduce stress on the body, and prevent complications such as acute chest syndrome.