The nurse is caring for a client who has just been admitted for vaso-occlusive sickle cell crisis. The client's Vital signs are: HR 1 10/min, BP 138/82, RR 22, Sp02 97% on 2 liters oxygen by nasal cannula. T. 98.8. pain 10/10 to the left lower extremity. Which of the following actions should the nurse take first?
Increase oxygen to 6 liters per minute.
Administer PRN Morphine Sulfate IV push for pain.
Request an order for a PRN antihypertensive medication.
Begin administering prescribed IV fluids.
The Correct Answer is B
A. The client’s SpO2 is already at 97%, so increasing oxygen is unnecessary. Oxygen is only required if hypoxia is present.
B. Pain management is the priority in vaso-occlusive crisis. Severe pain leads to stress, increasing oxygen demand and worsening sickling. IV opioids (e.g., morphine) are the standard treatment.
C. The BP is elevated but not critically high, and pain-related stress may be contributing. Treating pain first is the priority.
D. IV fluids help with hydration and reducing sickling, but pain management should be addressed first to provide immediate relief.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Holding direct pressure is important, but sterile gauze should be used to reduce infection risk.
B. A platelet transfusion is not routinely given unless the client has severe thrombocytopenia with active bleeding.
C. Applying pressure with sterile gauze is the appropriate nursing intervention to control bleeding and reduce the risk of hematoma formation after a bone marrow aspiration.
D. A type and crossmatch for blood transfusion is unnecessary unless the client has symptomatic anemia requiring intervention.
Correct Answer is A
Explanation
A. After initial HIV infection, clients typically enter a latent phase where symptoms subside, but the virus continues to replicate. This phase can last for years before progressing to AIDS when the CD4+ T-cell count drops below 200.
B. Symptoms generally do not correlate with a CD4+ count of 500; mild immunosuppression may begin at this level, but the client remains asymptomatic.
C. The virus is still active and causing immune system damage, even when symptoms are absent.
D. HIV transmission can still occur during the asymptomatic phase, especially if viral load is detectable.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.