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 C
Explanation
A. Elevating the affected part is correct and helps reduce swelling and bleeding.
B. Resting the affected area is appropriate and will help minimize movement and further bleeding.
C. Applying heat is not recommended for bleeding episodes as it can increase blood flow and exacerbate bleeding; ice is generally recommended.
D. Compressing the site is appropriate as it helps control bleeding and provides pressure to the affected area.
Correct Answer is B
Explanation
A. While prophylactic antibiotics may be considered, they are not standard for all procedures in hemophilia management.
B. Recombinant factor VIII is essential to ensure adequate clotting during and after the extraction, minimizing the risk of bleeding complications.
C. Packed RBCs may be needed for severe anemia but are not a standard preventive measure for hemophilia management during dental procedures.
D. Fresh frozen plasma can provide clotting factors but is not the preferred treatment for hemophilia A, where specific factor VIII replacement is needed.
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