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NurseDive Free Nursing Practice Question
A nurse is contributing to the plan of care for a school-age child who has sickle-cell disease and is experiencing a vaso-occlusive crisis. Which of the following should the nurse recommend to include in the plan of care?
A. Limit fluid intake during the evening
Limit fluid intake during the evening: Fluid intake is important in sickle-cell disease to prevent dehydration and maintain adequate blood flow. Restricting fluid intake during a vaso-occlusive crisis can further contribute to dehydration and may worsen the crisis. It is important to encourage fluid intake unless otherwise instructed by the healthcare provider.
B. Perform passive range-of-motion exercises.
During a vaso-occlusive crisis in sickle-cell disease, blood flow to certain areas of the body may be restricted, leading to pain and tissue damage. Passive range-of-motion exercises can help promote blood circulation and prevent joint stiffness and further complications. These exercises involve gently moving the child's joints through their full range of motion without active participation from the child.
C. Apply cold compresses to painful areas.
Apply cold compresses to painful areas: Cold compresses are not recommended during a vaso-occlusive crisis in sickle-cell disease. Cold temperatures can cause vasoconstriction and further worsen the blood flow to affected areas, leading to increased pain and tissue damage. Warm compresses or warm packs may be used to promote vasodilation and provide pain relief.
D. Provide a low-protein diet
Provide a low-protein diet: A low-protein diet is not specifically indicated in the plan of care for a vaso- occlusive crisis in sickle-cell disease. Adequate protein intake is important for overall nutritional needs and tissue repair. The focus of nutritional management in sickle-cell disease is usually on a well-balanced diet that includes adequate hydration and appropriate nutrient intake.
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Full Explanation
b. Perform passive range-of-motion exercises.
During a vaso-occlusive crisis in sickle-cell disease, blood flow to certain areas of the body may be restricted, leading to pain and tissue damage. Passive range-of-motion exercises can help promote blood circulation and prevent joint stiffness and further complications. These exercises involve gently moving the child's joints through their full range of motion without active participation from the child.
Explanation for the other options:
a. Limit fluid intake during the evening: Fluid intake is important in sickle-cell disease to prevent dehydration and maintain adequate blood flow. Restricting fluid intake during a vaso-occlusive crisis can further contribute to dehydration and may worsen the crisis. It is important to encourage fluid intake unless otherwise instructed by the healthcare provider.
c. Apply cold compresses to painful areas: Cold compresses are not recommended during a vaso-occlusive crisis in sickle-cell disease. Cold temperatures can cause vasoconstriction and further worsen the blood flow to affected areas, leading to increased pain and tissue damage. Warm compresses or warm packs may be used to promote vasodilation and provide pain relief.
d. Provide a low-protein diet: A low-protein diet is not specifically indicated in the plan of care for a vaso- occlusive crisis in sickle-cell disease. Adequate protein intake is important for overall nutritional needs and tissue repair. The focus of nutritional management in sickle-cell disease is usually on a well-balanced diet that includes adequate hydration and appropriate nutrient intake.
In summary, performing passive range-of-motion exercises is an appropriate intervention to include in the
plan of care for a school-age child experiencing a vaso-occlusive crisis in sickle-cell disease.
Similar Questions
A nurse is providing change-of-shift report for a client who has heart failure. Which of the following information should the nurse notinclude in the report?
A. The client's most recent blood pressure reading was 110/60 mm Hg.
The client's most recent blood pressure reading is an important piece of information that the incoming nurse should be aware of.
B. The client's morning laboratory results included a potassium level of 4.9 mg/dL.
The client'smorning laboratory results are an important pieceof information that the incoming nurse should be aware of.
C. The client has +2 pitting edema in the lower extremities.
The client'spresence of pitting edema in the lower extremities (option c) is an important piece of information that the incoming nurse should be aware of.
D. The client's partner assisted them with their meal tray.
The client's partner assisting them with their meal tray is not as important as the other information and may not need to be included in the change-of-shift report.
Full Explanation
The client's partner assisting them with their meal tray (option d) is not as important as the other information and may not need to be included in the change-of-shift report.
A nurse providing change-of-shift report for a client who has heart failure should include all of the above information in the report.
The client's most recent blood pressure reading, morning laboratory results, and presence of pitting edema in the lower extremities are all important pieces of information that the incoming nurse should be aware of.
A nurse is collecting a sputum specimen from a client for culture and sensitivity. Which of the following actions should the nurse take?
A. Collect 2 mL of sputum in an emesis basin
A) Collect 2 mL of sputum in an emesis basin: Collecting sputum in an emesis basin is inappropriate for laboratory testing. The sputum should be collected directly into a sterile container to prevent contamination. This ensures that the culture and sensitivity results are accurate and reflect the client's true respiratory pathogens.
B. Instruct the client to rinse with an antiseptic mouthwash prior to specimen collection.
B) Instruct the client to rinse with an antiseptic mouthwash prior to specimen collection: Using an antiseptic mouthwash before collecting a sputum sample is not recommended because it may alter the flora present in the sputum, leading to inaccurate culture results. Instead, the client should rinse their mouth with plain water to clear excess saliva or food debris.
C. Swab the oropharynx with a sterile swab
C) Swab the oropharynx with a sterile swab: Swabbing the oropharynx does not obtain sputum from the lungs but instead gathers a sample from the throat, which may not be reflective of lower respiratory infections. A proper sputum sample is produced through a deep cough to collect material directly from the lungs.
D. Refrigerate the specimen until the time of transport to the laboratory
D) Refrigerate the specimen until the time of transport to the laboratory: Refrigerating the sputum specimen helps to preserve its integrity by preventing the overgrowth of bacteria or other pathogens until it can be transported to the laboratory. Proper refrigeration ensures that the culture and sensitivity results remain accurate.
Full Explanation
Answer: D
Rationale:
A) Collect 2 mL of sputum in an emesis basin: Collecting sputum in an emesis basin is inappropriate for laboratory testing. The sputum should be collected directly into a sterile container to prevent contamination. This ensures that the culture and sensitivity results are accurate and reflect the client's true respiratory pathogens.
B) Instruct the client to rinse with an antiseptic mouthwash prior to specimen collection: Using an antiseptic mouthwash before collecting a sputum sample is not recommended because it may alter the flora present in the sputum, leading to inaccurate culture results. Instead, the client should rinse their mouth with plain water to clear excess saliva or food debris.
C) Swab the oropharynx with a sterile swab: Swabbing the oropharynx does not obtain sputum from the lungs but instead gathers a sample from the throat, which may not be reflective of lower respiratory infections. A proper sputum sample is produced through a deep cough to collect material directly from the lungs.
D) Refrigerate the specimen until the time of transport to the laboratory: Refrigerating the sputum specimen helps to preserve its integrity by preventing the overgrowth of bacteria or other pathogens until it can be transported to the laboratory. Proper refrigeration ensures that the culture and sensitivity results remain accurate.
A nurse is reinforcing discharge teaching with a client who has type 1 diabetes mellitus. Which of the following client statements indicates an understanding of the teaching?
A. "I will dispose of insulin needles in a puncture-proof container."
A client statement that indicates an understanding of discharge teaching for type 1 diabetes mellitus is "I will dispose of insulin needles in a puncture-proof container." This is the correct way to dispose of insulin needles to prevent accidental needle sticks.
B. "I will store opened insulin vials in my refrigerator."
Opened insulin vials do not need to be stored in the refrigerator, but should be kept at room temperature.
C. "I will shake the insulin vial before drawing it into the syringe."
Insulin vials should not be shakenas this can cause the insulin to break down.
D. "I will expect my regular insulin to appear cloudy."
Regular insulin should appear clear, not cloudy.
Full Explanation
A client statement that indicates an understanding of discharge teaching for type 1 diabetes mellitus is "I will dispose of insulin needles in a puncture-proof container." This is the correct way to dispose of insulin needles to prevent accidental needle sticks.
The other options are not correct.
b) Opened insulin vials do not need to be stored in the refrigerator, but should be kept at room temperature.
c) Insulin vials should not be shaken as this can cause the insulin to break down.
d) Regular insulin should appear clear, not cloudy.