A nurse is providing care for an adolescent who was brought to the emergency department (ED) by their guardians due to pain in the left arm that started the previous evening.

The adolescent has a history of sickle cell disease diagnosed at age 4. They have a prescription for oral morphine sulfate and took one dose the previous evening at 1800 and another this morning at 0900.

The adolescent reports no relief from pain, rating it as 9 on a scale of 0 to 10. For each potential provider’s prescription, specify if the prescription is anticipated, nonessential, or contraindicated for the client.

Intravenous fluids (IVF) at maintenance rate

Meperidine IV for pain

Ice packs to the affected area for 15 min on/15 min off

Oxygen 2 L/min via nasal cannula

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"C"},"C":{"answers":"B"},"D":{"answers":"A"}}

Choice A rationale
Intravenous fluids (IVF) at maintenance rate is anticipated for the client. Dehydration can increase the viscosity of the blood and promote sickling in clients with sickle cell disease. Therefore, maintaining hydration is crucial in managing sickle cell crises.
Choice B rationale
Meperidine IV for pain is contraindicated for the client. Meperidine has been associated with a higher risk of seizures, especially in clients with kidney dysfunction, which can occur in sickle cell disease due to sickling in the renal vasculature.
Choice C rationale
Ice packs to the affected area for 15 min on/15 min off is nonessential for the client. While cold therapy can help reduce inflammation and numb pain, it can also lead to vasoconstriction, which can potentially exacerbate sickling. Therefore, it’s generally recommended to use warm compresses rather than ice packs in clients with sickle cell disease.
Choice D rationale
Oxygen 2 L/min via nasal cannula is anticipated for the client. Hypoxia can trigger sickling in clients with sickle cell disease, so oxygen therapy is often used to increase oxygen saturation and reduce the risk of sickling.

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Correct Answer is B

Explanation

Choice A rationale
Performing nasopharyngeal suctioning for a maximum of 5 seconds is not a recommended action for an infant diagnosed with Tetralogy of Fallot. This procedure is typically used to clear the airway in infants with respiratory distress, not heart conditions.
Choice B rationale
Positioning the infant in a knee-chest position can help increase blood flow to the lungs, which is beneficial for an infant with Tetralogy of Fallot. This condition involves a combination of heart defects that affect the normal flow of blood through the heart.
Choice C rationale
Administering morphine via IV bolus is not a recommended action for an infant diagnosed with Tetralogy of Fallot. While morphine is a powerful pain reliever, it is not typically used in the management of this condition.
Choice D rationale
Providing 100% oxygen by face mask is not a recommended action for an infant diagnosed with Tetralogy of Fallot. While supplemental oxygen can help increase the amount of oxygen in the blood, it does not address the underlying heart defects associated with this condition.

A. Pulmonic stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy. B. Aortic stenosis, atrial septal defect, overriding aorta, left ventricular hypertrophy. C. Pulmonary stenosis, ventricular septal defect, aortic hypertrophy, left ventricular hypertrophy. D. Aortic stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy.

Correct Answer is A

Explanation

Choice A rationale
Tetralogy of Fallot is a congenital heart defect that includes four specific heart abnormalities: pulmonic stenosis, ventricular septal defect, overriding aorta, and right ventricular hypertrophy.
Choice B rationale
This choice incorrectly identifies aortic stenosis and atrial septal defect as components of Tetralogy of Fallot. In fact, the condition involves pulmonic stenosis and a ventricular septal defect.
Choice C rationale
This choice incorrectly identifies pulmonary stenosis and aortic hypertrophy as components of Tetralogy of Fallot. In fact, the condition involves pulmonic stenosis and right ventricular hypertrophy.
Choice D rationale
This choice incorrectly identifies aortic stenosis as a component of Tetralogy of Fallot. In fact, the condition involves pulmonic stenosis.

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Naxlex Comprehensive Predictor Exams

Given the medical history and nurses’ notes of an infant diagnosed with Tetralogy of Fallot, which of the following actions should the nurse take?

Correct Answer is B

Explanation

Can you identify the structural anomalies that make up Tetralogy of Fallot?

Correct Answer is A

Explanation

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