A nurse is planning care for an adolescent client who has sickle cell anemia and is experiencing a vaso-occlusive crisis. Which of the following interventions is the nurse's priority?

Applying heat to the affected areas

Administering prophylactic antibiotics

Administering the pneumococcal vaccine

Promoting bed rest

Answer and Explanation

The Correct Answer is A

A. Applying heat to the affected areas: Heat application promotes vasodilation and helps relieve pain in vaso-occlusive crises. This is a priority because managing pain is critical during a crisis. It can also help improve blood flow and alleviate discomfort.
B. Administering prophylactic antibiotics: While prophylactic antibiotics are important in preventing infections in sickle cell anemia, this is not the immediate priority during a vaso-occlusive crisis.
C. Administering the pneumococcal vaccine: While vaccination is important, it is not a priority during a vaso-occlusive crisis.
D. Promoting bed rest: Bed rest is generally recommended to reduce energy expenditure, but it does not directly address the acute pain or vaso-occlusion that needs to be managed immediately.

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Correct Answer is ["A","B","C","G","H","I","J"]

Explanation

A. Intake and output: The infant has not fed in 8 hours and has only had 1 wet diaper during this time, which is concerning for dehydration or inadequate intake. The decreased output requires immediate follow-up to prevent further dehydration and assess fluid needs.
B. Heart rate: The heart rate of 180/min is elevated for an infant, potentially indicating dehydration, fever, or respiratory distress. Tachycardia can also signify compensation for hypoxia.
C. Respiratory rate: A respiratory rate of 60/min is elevated for an infant and indicates respiratory distress, compounded by retractions and diminished lung sounds in the right lobes.
D. Bowel sounds: Active bowel sounds in all four quadrants are a normal finding and do not indicate an acute issue.
E. Mucous membranes: While dry mucous membranes confirm dehydration, they are not the highest priority compared to respiratory distress or oxygen saturation.
F. Weight: Weight loss from 9 lb to 8 lb 8 oz is concerning for chronic dehydration or inadequate nutrition, but it does not require immediate action compared to acute respiratory and oxygenation issues.
G. Retractions: Moderate substernal and intercostal retractions are indicative of respiratory distress. This requires immediate follow-up to assess the severity of the distress and initiate appropriate interventions, such as supplemental oxygen or further evaluation.
H. Lung sounds: Diminished lung sounds in the right lobes and occasional coarse crackles are concerning for a respiratory infection or condition such as pneumonia or bronchiolitis. Immediate follow-up is required to assess the cause and severity of the respiratory findings.
I. Temperature: The infant has a fever, which is concerning, especially with poor feeding and lethargy. Fever in an infant can indicate a serious infection (e.g., sepsis, urinary tract infection, or pneumonia) that requires immediate medical attention and further investigation.
J. Oxygen saturation: An oxygen saturation of 92% is low for an infant, indicating hypoxia, likely due to respiratory compromise. Immediate intervention (e.g., oxygen therapy) is necessary to prevent further deterioration.

A. Administer the medication on an empty stomach. B. Entourage the child to brush their teeth after each meal. C. Crush the child's medication to mix with applesauce. D. Observe the child for diarrhea.

Correct Answer is B

Explanation

A. "Administer the medication on an empty stomach." Phenytoin can be taken with or without food. Administering with food can reduce stomach upset.
B. "Encourage the child to brush their teeth after each meal." Phenytoin increases the risk of gingival hyperplasia, so regular brushing helps maintain oral hygiene and prevents complications.
C. "Crush the child's medication to mix with applesauce." Extended-release capsules should not be crushed as this alters their intended release mechanism.
D. "Observe the child for diarrhea." Diarrhea is not a common side effect of phenytoin. Monitoring should focus on side effects like gingival overgrowth, nystagmus, or skin rashes.

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A nurse is planning care for an adolescent client who has sickle cell anemia and is experiencing a vaso-occlusive crisis. Which of the following interventions is the nurse's priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","B","C","G","H","I","J"]

Explanation

A nurse is providing discharge teaching to the parents of a school-age child who has epilepsy and a new prescription for phenytoin extended- release capsules. Which of the following instructions should the nurse include in the teaching?

Correct Answer is B

Explanation

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