Health Promotion and Maintenance
69. A nurse admits a teenager in sickle cell crisis to a pediatric unit. The child has an elevated heart rate but normal blood pressure, respiratory rate, and temperature. The child has an oxygen saturation of 98% on room air and rates pain in the extremities at an 8 on a 1-to-10 numeric pain rating scale. Which actions should the nurse perform at this time? Prioritize the nurse's actions by placing each correct intervention in priority order.
. Administer oxygen.
. Obtain the child's weight.
. Administer IV fluids as ordered.
. Monitor I&O.
. Obtain an order for pain medication via PCA.
. Apply cool, moist compresses to extremities.
Test-Taking Tip
When placing options in sequential order, consider whether assessments should be done before or after interventions. In child health, IV fluids and medications are based upon the child's weight; therefore, the weight should be assessed before these treatments can be safely administered.
Content Area: Child Health, Hematology; Integrated Process: Nursing Process, Analysis; Cognitive Level: Analysis; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/Potential for Alterations in Body Systems
Health Promotion and Maintenance
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Answer 1 is incorrect because the child's respiratory assessment did not reveal a need for supplemental oxygen at this time. Routine use of oxygen is not recommended for a child with sickle cell disease because it will not reverse sickling or treat pain. Answer 2 is correct because the nurse must first obtain an accurate weight before determining safe dosages of ordered medications and IV fluids. Additionally, the child's weight will be used to determine whether I&O are meeting appropriate targets. Answer 3 is correct because IV fluid administration is a priority treatment for the child in sickle cell crisis. After the child's weight is obtained, the nurse may safely administer the ordered IV fluids, being sure to calculate that the amount and rate is appropriate. Answer 4 is correct because the nurse should monitor intake and output for adequacy since hydration status is an important part of this child's assessment. I&O monitoring should take place after the child has been weighed and is started on IV fluids and medications. Answer 5 is correct because the child needs effective pain management, yet this is a lower priority than fluid administration. A teenager with a chronic painful condition is an excellent candidate for PCA (patient-controlled analgesia). Answer 6 is incorrect because warm compresses, not cool compresses, should be used to facilitate circulation in affected extremities.