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 ["A","B","C","D","E","F"]
Explanation
A. Avoiding bubble baths is important as they can irritate the urethra and exacerbate UTIs.
B. Wiping the perineal area from front to back is essential to prevent bacteria from the rectal area from entering the urinary tract.
C. Completing the course of prescribed antibiotics is crucial to fully eradicate the infection and prevent recurrence.
D. Encouraging frequent voiding helps to flush out bacteria from the urinary tract and prevent infection.
E. Wearing cotton underwear helps keep the area dry and reduce the risk of bacterial growth.
F. Encouraging frequent fluid intake aids in hydration and helps dilute the urine, reducing irritation and promoting flushing of bacteria.
Correct Answer is ["A","B","D"]
Explanation
A. Providing written information about the medication is important for ensuring the parents understand the treatment plan and can reference it later.
B. Discussing the potential adverse effects of the medication prepares the parents for what to monitor in their child and when to seek help.
C. Stopping the medication when the child feels better is incorrect, as it is essential to complete the full course of antibiotics to prevent resistance and recurrence of infection.
D. Explaining the reason why the child is taking the medication helps parents understand its importance and can enhance adherence to the treatment plan.
E. Advising against using a kitchen spoon for administering the medication is important, as it can lead to incorrect dosing; proper dosing devices should be used instead.
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