How can the nurse determine that the outcomes of nursing interventions have been successful for the client diagnosed with a sickle cell crisis? (SELECT ALL THAT APPLY)
The client is free of chest pain and dyspnea.
The client describes the importance of increasing fluid intake.
The client increases aerobic exercises to promote endurance.
The client's acute pain is controlled at 3 on a standard pain scale.
Correct Answer : A,B,D
Choice A reason:
Being free of chest pain and dyspnea is a significant indicator of successful nursing intervention in a sickle cell crisis. Chest pain and dyspnea can occur due to acute chest syndrome, a life-threatening complication of sickle cell disease characterized by vaso-occlusion in the pulmonary microcirculation. Effective pain management and oxygen therapy can alleviate these symptoms, reflecting improved respiratory function and gas exchange.
Choice B reason:
Educating the client on the importance of increasing fluid intake is crucial in managing sickle cell crisis. Adequate hydration helps to reduce blood viscosity and prevent sickling of red blood cells, which can lead to vaso-occlusive episodes. When a client verbalizes understanding and the importance of hydration, it demonstrates the effectiveness of patient education and the client's engagement in self-care.
Choice C reason:
While increasing aerobic exercises may promote endurance, it is not typically a short-term outcome measure for a sickle cell crisis. Exercise must be approached with caution in these clients, as it can increase the risk of a vaso-occlusive crisis due to dehydration and increased oxygen demand during a sickle cell crisis.
Choice D reason:
Control of acute pain to a level of 3 on a standard pain scale indicates successful pain management, a primary goal in the treatment of sickle cell crisis. Pain in sickle cell crisis is due to ischemia from obstructed blood flow by sickled cells. Effective analgesic administration and pain management strategies are essential to achieve this outcome.
Choice E reason:
A leukocyte count of 18,000/mm³ is above the normal range (4,500 to 11,000/mm³) and may indicate an infection or inflammation, which are common complications of sickle cell disease. However, this is not a direct outcome of nursing interventions aimed at managing a sickle cell crisis and thus is not a correct choice.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B"]
Explanation
Choice A reason:
This statement is incorrect. Insulin glargine is a long-acting insulin with a relatively steady effect and does not require eating within a specific timeframe after injection. It is designed to be injected once daily at any time of the day but at the same time every day.
Choice B reason:
This statement is incorrect. Insulin glargine should not be mixed with any other insulins in the same syringe. It is formulated to be clear and colorless, and mixing it with other insulins, especially rapid-acting insulins like lispro, can affect its action profile.
Choice C reason:
This statement is correct. Rotating the injection site is important to prevent lipodystrophy, which is the breakdown or buildup of fat beneath the skin that can occur with repeated injections at the same site. Rotating sites helps to ensure consistent insulin absorption.
Choice D reason:
This statement is correct. Insulin glargine should be administered in areas of subcutaneous fat, such as the upper arms, thighs, buttocks, or abdomen. The upper anterior aspect of the arm is an appropriate site for insulin injection.
Correct Answer is D
Explanation
Choice A Reason
Performing a bladder scan can help determine the volume of urine in the bladder and assess for urinary retention, which could contribute to bladder spasms. However, this is not typically the first intervention. The priority is to ensure that the catheter is patent and draining correctly, as blockages can cause immediate discomfort and increased spasms
Choice B Reason
Stopping the irrigation could be considered if there is a concern that the CBI is contributing to the spasms. However, this would not be the first action taken. It is essential first to assess the catheter's patency and the flow of the irrigation to rule out any obstruction or kinking causing the spasms.
Choice C Reason
Administering an oral analgesic may help alleviate the discomfort caused by bladder spasms, but it does not address the underlying cause. Pain relief is important, but the initial step should be to check for and resolve any mechanical issues with the catheter system that could be causing the spasms.
Choice D Reason
Ensuring that the catheter is draining properly is the first and most crucial intervention. If the catheter is blocked or kinked, it can cause bladder distention and increased spasms. Checking the catheter's patency and the flow of irrigation can quickly resolve the issue and provide relief to the patient. If the catheter is found to be obstructed, resolving the blockage can decrease the severity of the spasms and improve the patient's comfort.
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