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","E","F"]

Explanation

A. Ensure comfortable seating at eye level for the client and nurse: Establishes a non-intimidating environment, helping the client feel more at ease.

B. Provide seating for the client so that the client faces a strong light: Incorrect; this may cause discomfort and make the client feel scrutinized.

C. Ensure that the distance between the client and nurse is at least 7 ft: Too great a distance for effective communication; ideal distance is 3-4 feet.

D. Place a chair for the client across from the nurse's desk: Creates a formal, potentially intimidating setting, discouraging openness.

E. Set the room temperature at a comfortable level: Ensures physical comfort, aiding in client relaxation and openness.

F. Remove distracting objects from the interviewing area: Minimizes potential distractions, keeping the client focused and the environment conducive to communication.

A. Hang a bag of 0.9% normal saline with 5% dextrose at the bedside (D5%NS) B. Verify the client's name and blood type with a second nurse C. Infuse the unit of blood within 4 hours. D. Obtain baseline vital signs prior to starting the transfusion E. Continuously monitor the client during the first 15 minutes of the transfusion F. Insert an 18-gauge intravenous catheter G. Insert a 22-gauge intravenous catheter

Correct Answer is ["B","C","D","E","F"]

Explanation

A. Hanging a bag of 0.9% normal saline with 5% dextrose (D5%NS) is incorrect; only normal saline (0.9% NS) should be used to prime the blood transfusion line to avoid hemolysis.

B. Verifying the client's name and blood type with a second nurse is a critical safety measure to prevent transfusion reactions and ensure the correct blood product is given.

C. Infusing the unit of blood within 4 hours is essential to reduce the risk of bacterial growth in the blood product.

D. Obtaining baseline vital signs prior to starting the transfusion is important to assess the client's condition and monitor for any changes during the transfusion.

E. Continuously monitoring the client during the first 15 minutes of the transfusion is vital for detecting any signs of a transfusion reaction promptly.

F. Inserting an 18-gauge intravenous catheter is recommended for blood transfusions as it provides a sufficient lumen to accommodate the blood flow.

G. Inserting a 22-gauge intravenous catheter is acceptable for some transfusions, but an 18-gauge is preferred for larger blood products.

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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

The nurse is setting up the physical environment for an interview with a client and plans to obtain subjective data regarding the client's health. Which interventions are appropriate? Select three options that apply.

Correct Answer is ["A","E","F"]

Explanation

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Correct Answer is ["B","C","D","E","F"]

Explanation

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