The nurse is providing care to an infant with sickle cell anaemia who has increased work of breathing, a fever, coarse crackles upon auscultation, oxygen saturation of 89%, and inconsolable crying. Which intervention will the nurse perform first?

Prepare to hang hypotonic fluids.

Administer oxygen via nasal cannula.

Provide patient education on acute chest syndrome.

Give a dose of morphine sulphate.

Answer and Explanation

The Correct Answer is B

Choice A reason: Preparing to hang hypotonic fluids is not the immediate priority in this situation. While hydration is important for managing sickle cell anaemia, the infant's respiratory distress and low oxygen saturation levels indicate that addressing oxygenation should be the first step. Hypotonic fluids may be considered after stabilizing the patient's breathing and oxygen levels.

Choice B reason: Administering oxygen via nasal cannula is the priority intervention given the infant's symptoms. The infant has increased work of breathing, a fever, coarse crackles upon auscultation, and low oxygen saturation (89%). Providing supplemental oxygen is crucial to improve oxygenation and alleviate respiratory distress. Prompt intervention is necessary to prevent further complications and stabilize the patient's condition.

Choice C reason: Providing patient education on acute chest syndrome is important, but it is not the immediate priority in this emergency situation. Education can be given once the infant's acute symptoms are managed and stabilized. The focus should be on addressing the critical needs first, such as oxygenation and respiratory support.

Choice D reason: Giving a dose of morphine sulphate may help manage pain, but it is not the first priority in this scenario. The infant's respiratory status and oxygenation levels are more critical and require immediate attention. Pain management can be addressed after ensuring the infant's breathing and oxygen levels are stabilized.

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

Explanation

Choice A reason: Facilitating an early discharge is not appropriate in this case. Patients with PPROM require careful monitoring and management to prevent infections and other complications.

Choice B reason: Discontinuing oxycodone administration may be necessary to prevent potential adverse effects on both the patient and the baby, especially considering the patient's recent delivery and current condition.

Choice C reason: Restricting visitor time can help reduce the risk of infection, especially for a patient with PPROM and a newborn who may have a compromised immune system.

Choice D reason: Providing a breast pump is important to help the mother establish and maintain lactation, especially if the baby is premature and may have difficulty breastfeeding directly.

A. Bronchodilator B. Digestive enzyme C. Mucolytic D. Aerosolized antibiotic

Correct Answer is B

Explanation

Choice A reason: Bronchodilators are medications that help open the airways in the lungs, making it easier to breathe. They are often used for managing respiratory symptoms in cystic fibrosis, but they are not typically required specifically before meals.

Choice B reason: Digestive enzymes are essential for children with cystic fibrosis to take before meals. These enzymes help the body digest and absorb nutrients from food, which is crucial because cystic fibrosis can impair the pancreas's ability to produce these enzymes naturally.

Choice C reason: Mucolytics are medications that help thin and loosen mucus in the lungs, making it easier to cough up and clear from the airways. While important for managing respiratory symptoms, they are not specifically needed before meals.

Choice D reason: Aerosolized antibiotics are used to treat or prevent lung infections in individuals with cystic fibrosis. They are administered via inhalation and are not tied to meal times but rather prescribed as part of a daily treatment regimen.

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The nurse is providing care to an infant with sickle cell anaemia who has increased work of breathing, a fever, coarse crackles upon auscultation, oxygen saturation of 89%, and inconsolable crying. Which intervention will the nurse perform first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a G4P1, 31 weeks and 2 days gestation, 41-year-old patient, with premature prolonged rupture of membranes (PPROM) 7 hours after delivery. Which interventions will the nurse include in the plan of care? Select all that apply.

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Explanation

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