The client with sickle cell disease (SCD) has recently been sick and is now experiencing a vaso-occlusive crisis. Which priority interventions should the nurse implement?

Encourage frequent ambulation in the hallways

Monitor the client's RBC count every 4 hours

Treat them in an outpatient setting

Maintain IV fluids, administer pain medications, and provide supplemental oxygen

Answer and Explanation

The Correct Answer is D

A. Encouraging frequent ambulation is not appropriate during a vaso-occlusive crisis, as it can exacerbate pain and further compromise blood flow.

B. While monitoring the RBC count is important, it is not the most immediate intervention during a crisis. The focus should be on managing pain and preventing complications.

C. Treating the client in an outpatient setting is inappropriate during a vaso-occlusive crisis, which typically requires inpatient care for effective pain management and hydration.

D. Maintaining IV fluids, administering pain medications, and providing supplemental oxygen are critical interventions that address the acute needs of the client in crisis, aiming to alleviate pain and improve oxygenation.

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Correct Answer is A

Explanation

A. Ensuring the blood is compatible with the client's blood type is critical in preventing an acute hemolytic reaction, as incompatible blood transfusions can cause serious, potentially life-threatening reactions.

B. Administering the transfusion rapidly can increase the risk of complications and does not prevent hemolytic reactions; transfusions should be given at a safe rate based on the client's condition.

C. Using a blood warmer is not a standard intervention to prevent hemolytic reactions; it's typically used in specific cases such as massive transfusions or hypothermia, but it does not address compatibility.

D. Administering prophylactic antihistamines is not a recommended practice to prevent hemolytic reactions; it is more relevant for preventing allergic reactions associated with transfusions.

A. Blood transfusions B. Daily hydroxyurea C. Iron supplements D. Vitamin B injections

Correct Answer is D

Explanation

A. Blood transfusions are not a primary treatment for pernicious anemia; they may be used in severe cases but do not address the underlying cause of the condition, which is vitamin B12 deficiency.

B. Daily hydroxyurea is primarily used to treat certain types of cancer and sickle cell disease, not pernicious anemia.

C. Iron supplements are not effective in treating pernicious anemia, as the condition is due to a deficiency of vitamin B12, not iron.

D. Vitamin B injections are the correct intervention for pernicious anemia because the condition results from an inability to absorb vitamin B12 due to a lack of intrinsic factor, making injections necessary to restore vitamin levels.

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The client with sickle cell disease (SCD) has recently been sick and is now experiencing a vaso-occlusive crisis. Which priority interventions should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to transfuse a unit of packed red blood cells for a client with severe anemia. The nurse should identify that which of the following interventions will help prevent an acute hemolytic reaction?

Correct Answer is A

Explanation

A nurse is planning care for a client with pernicious anemia. Which intervention should the nurse plan to implement?

Correct Answer is D

Explanation

Which nursing interventions are appropriate for a nurse administering a blood transfusion? Select All That Apply

A nurse is monitoring a client receiving a blood transfusion. Which of the following findings indicates an allergic transfusion reaction?

A nurse is caring for a client with sickle cell anemia. The client asks, "Why am I in so much pain?" What is an appropriate response from the nurse to make to this client?

A nurse is assessing a client who is receiving a unit of packed red blood cells. Which client statement suggests manifestation of an acute hemolytic reaction?

A client with iron deficiency anemia is prescribed ferrous sulfate. Which instruction by the nurse is most appropriate to include in the client's teaching plan?

A nurse is assessing a client who is postoperative and has anemia due to excess blood loss following surgery. The client's hemoglobin is at 7 g/dL. Which of the following findings should the nurse expect this client to report?

A nurse is caring for a client who has human immunodeficiency virus (HIV). Which laboratory value should the nurse alert the provider of?

A nurse is caring for a client who is coming to the clinic for human immunodeficiency virus (HIV) testing. The patient's enzyme-linked immunosorbent assay (ELISA) results are positive. Which test will be used to confirm the diagnosis of HIV?