A nurse is planning care for an adolescent client.
Apply cold compresses to the joints
Encourage bedrest
Provide oxygen at 6 min via nasal cannula
Restrict fluid intake to 1,400 mL/day.
Obtain consent for a blood transfusion.
Administer IV fluids.
Perform passive range-of-motion exercises.
Correct Answer : B,E,F
A. Cold compresses may not be appropriate in this case. In sickle cell crises, warmth is typically encouraged to promote circulation and reduce pain, whereas cold can constrict blood vessels and potentially worsen ischemia.
B. Bedrest is appropriate for this client to minimize energy expenditure and allow the body to focus on healing. Pain management is also a priority, and limiting activity can help manage pain levels.
C. While oxygen can be helpful in managing hypoxia, the client’s oxygen saturation is currently 96% on room air, indicating adequate oxygenation. Routine administration of oxygen is not indicated in this scenario.
D. In sickle cell disease, hydration is important to reduce blood viscosity and prevent crises. Therefore, the nurse should encourage adequate fluid intake unless contraindicated.
E. The client has a significantly low hemoglobin level (5 g/dL), which may necessitate a blood transfusion to improve oxygen-carrying capacity and treat anemia. Consent should be obtained as part of the preparation for this intervention.
F. Administering IV fluids is essential for rehydration and improving circulation, which can help alleviate pain and prevent further sickling of cells.
G. While passive range-of-motion exercises can be beneficial, they are generally not recommended during acute pain episodes as they may exacerbate discomfort and pain. The focus should be on pain management and rest.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Bagels with cream cheese and lox are not recommended as lox may carry a risk of contamination.
B. A vanilla milkshake made with pasteurized milk is safe for a neutropenic diet as pasteurization kills harmful bacteria.
C. Ham and cheese sandwiches may not be safe unless the ham is fully cooked, as deli meats can harbor bacteria.
D. Sushi is not appropriate for a neutropenic diet due to the risk of raw fish and potential bacteria.
Correct Answer is B
Explanation
A. Passing flatus every 30 minutes indicates bowel activity and suggests that the child may be able to resume oral intake.
B. Absent bowel sounds indicate a lack of gastrointestinal function, which supports the continuation of NPO status until bowel function returns.
C. An increase in abdominal girth, even by 1 cm, can be concerning postoperatively and may indicate fluid retention or other issues, warranting further assessment.
D. Pain at the operative site is expected post-surgery, but it does not directly relate to the child’s ability to resume oral intake.
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