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The nurse is admitting a 6-year-old child with Sickle Cell Anemia who is being admitted for vaso-occlusive crisis.
Exhibits
The nurse is planning the nursing care for this child and anticipates which of the following to be a part of the plan of care for a child in vaso-occlusive crisis? For each potential intervention, click to specify if the intervention is anticipated or contraindicated.

A.

Monitor RLE pulses with vital signs

B.

Administer Oxycodone 3 mg Q3-4 hours PRN for pain

C.

Continue IV NSS bolus @ 67 ml/hour

D.

Decrease 02 to 2 L/min

Answer and Explanation

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

Monitor RLE pulses with vital signs:
Anticipated. Regular monitoring of pulses, especially in areas of pain or tenderness, is essential to assess for adequate perfusion and circulation, which can be compromised in vaso-occlusive crisis.
Administer Oxycodone 3 mg Q3-4 hours PRN for pain:
Anticipated. Pain management is crucial in treating vaso-occlusive crises. Continuation of pain medication is necessary to keep the child's pain under control.
Continue IV NSS bolus @ 67 ml/hour:
Anticipated. Hydration is vital in managing a vaso-occlusive crisis as it helps to reduce blood viscosity and prevent further sickling of red blood cells.
Decrease O2 to 2 L/min:
Contraindicated. Maintaining adequate oxygenation is important in managing vaso-occlusive crises to ensure that tissues receive sufficient oxygen and to prevent further sickling of red blood cells. Decreasing oxygen flow can compromise oxygen delivery.
 


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Related Questions

Correct Answer is B

Explanation

A. Decreased urine output and dark brown urine are concerning but not immediately life-threatening.
B. Lethargy, confusion, headache, and double vision are signs of severe hypertension and possibly hypertensive encephalopathy, which require immediate attention.
C. Elevated BUN, creatinine, and ESR are indicative of kidney dysfunction but are not as immediately concerning as neurological symptoms.
D. While elevated BP and irritability are concerning, they are not as immediately critical as the neurological symptoms in option B.

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

Explanation

Monitor RLE pulses with vital signs:
Anticipated. Regular monitoring of pulses, especially in areas of pain or tenderness, is essential to assess for adequate perfusion and circulation, which can be compromised in vaso-occlusive crisis.
Administer Oxycodone 3 mg Q3-4 hours PRN for pain:
Anticipated. Pain management is crucial in treating vaso-occlusive crises. Continuation of pain medication is necessary to keep the child's pain under control.
Continue IV NSS bolus @ 67 ml/hour:
Anticipated. Hydration is vital in managing a vaso-occlusive crisis as it helps to reduce blood viscosity and prevent further sickling of red blood cells.
Decrease O2 to 2 L/min:
Contraindicated. Maintaining adequate oxygenation is important in managing vaso-occlusive crises to ensure that tissues receive sufficient oxygen and to prevent further sickling of red blood cells. Decreasing oxygen flow can compromise oxygen delivery.

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