Health Promotion and Maintenance
7. A hospitalized child is experiencing sickle cell vasoocclusive crisis. The child is currently receiving an intravenous (IV) fluid bolus, pain medication every 4 hours, and warm compresses to the extremities per physician orders. During the midday assessment, the child reports no pain. Which action should a nurse take?
. Continue to apply warm compresses per physician order.
. Hold the next dosage of pain medication.
. Hold the next round of warm compresses.
. Contact the physician for a change in orders.
Test-Taking Tip
Whenever a client is in the middle of receiving a prescribed treatment, such as a fluid bolus, the nurse should continue supportive measures until the treatment is complete and the nurse is able to reassess. Choose the one option that is different–"continue."
Content Area: Child Health, Cardiovascular; Integrated Process: Nursing Process, Implementation; Cognitive Level: Analysis; Client Need/Subneed: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems
Health Promotion and Maintenance
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Answer 1 is the correct response since the child is currently receiving a fluid bolus, which may be providing temporary improvement of pain symptoms. Ongoing application of warm compresses will continue to promote circulation in the extremities, thereby preventing pain. Once the fluid bolus is completed, the nurse should reassess the child's pain and circulation. Answer 2 is incorrect because around-the-clock dosing of pain medication is the best way to prevent pain in a child with a chronic painful condition such as sickle cell crisis. Answer 3 is incorrect because cessation of the warm compresses may lead to decreased circulation in the extremities, resulting in a recurrence of the pain. Answer 4 is incorrect because both warm compresses and pain medication should be continued to prevent recurrence of pain. A change in orders is not necessary at this time, and the nurse should reassess the child following the IV fluid bolus.