Is this an actual question from a NCLEX review book? There is not nearly enough info to me there. Pain is a vital sign as is the heart rate. The question just says they are going through withdrawal, not what is accompanying the withdrawal as we don't know what is accompanying the sickle cell crisis.
But if someone was admitted for sickle cell crisis and the fact that pain is indicative that the crisis is getting worse, I would go and do an assessment, looking at their O2 sat rate and respiratory rate. 107 is not alarming on the heart rate. It is going to be elevated because they are withdrawing. I'm trying to understand where the circulation problem is being read into this.
I have always been taught you cannot read information that is not there. I was also taught that you assess every hour on a COWS form with someone who is withdrawing. The fact the sickle cell patient is complaining of pain tells me something is happening in the crisis, provided their routine pain medication has not warn off. Sickle cell is painful. If they were admitted, they were on some kind of pain medication. This is why I saying there is not near info info. Also, a nurse would be given more info in report.
It's a question I made up. I think it's a good question and fairly straightforward as are most questions on NCLEX. Most people who responded came to the right conclusion as to the answer. I learned in nursing school that pain is the fifth vital sign. However, I learned in my NCLEX review course that pain is also considered psychosocial unless it is unexpected and therefore a sign of a new physiological process. The patient in sickle cell crisis is going to be in pain. Over a number of days, the pain gets better with oxygen, fluids, and sometimes blood transfusions and is relieved by narcotics. The pain is there and is a sign of the crisis. There is no indication in the question of the pain getting worse or being unrelieved.
The patient in alcohol withdrawal needs immediate attention. Have you ever seen a nasty case of SVT that happened as a result of untreated ETOH withdrawal. 107 is still high. Whether it's 107, 117, or 127 it's still tachycardia. It will be 107 one minute 127 the next if left untreated.
Tachycardia is stressful on the heart and increases myocardial oxygen demand. It's a circulation issue because it involves the heart. Even if it is a sign of alcohol withdrawal, it still has it's own physiological reason. Dehydration?
In real life, I would probably medicate my sickle cell patient first, unless my ETOH patient was very agitated.
To divobari - Lucia is the change in her name Lucy (of Mrs. Lucy Muir, the heroine of The Ghost & Mrs. Muir) as given to her by The Captain (Rex Harrison - am swooning). It's among my top favorite -est movies, that and Jane Eyre with Orson Welles (quick - the smelling salts again!).
Now second clue - guess what my favorite -est old time TV show is? It debuted in 10/1951 with a crazy redhead married to fiery Cuban bandleader.
That's amazing! Yes, I love Lucy, with Lucille Ball! I love that series. They were true trailblazers! I think I'm gonna find some old episodes and watch it!
It's a question I made up. I think it's a good question and fairly straightforward as are most questions on NCLEX. Most people who responded came to the right conclusion as to the answer. I learned in nursing school that pain is the fifth vital sign. However, I learned in my NCLEX review course that pain is also considered psychosocial unless it is unexpected and therefore a sign of a new physiological process. The patient in sickle cell crisis is going to be in pain. Over a number of days, the pain gets better with oxygen, fluids, and sometimes blood transfusions and is relieved by narcotics. The pain is there and is a sign of the crisis. There is no indication in the question of the pain getting worse or being unrelieved.
The patient in alcohol withdrawal needs immediate attention. Have you ever seen a nasty case of SVT that happened as a result of untreated ETOH withdrawal. 107 is still high. Whether it's 107, 117, or 127 it's still tachycardia. It will be 107 one minute 127 the next if left untreated.
Tachycardia is stressful on the heart and increases myocardial oxygen demand. It's a circulation issue because it involves the heart. Even if it is a sign of alcohol withdrawal, it still has it's own physiological reason. Dehydration?
In real life, I would probably medicate my sickle cell patient first, unless my ETOH patient was very agitated.
However, not on NCLEX.
Yeah... I am respectfully backing away from this one - it is clearly not an "exchange". I genuinely wish you guys the best in your careers!!
In caring for a client undergoing orthopedic surgery, what is the most important post operative nursing intervention.
1) Update the client on the plan of care.
2) Monitor bowel sounds.
3) Instruct client on use of the incentive spirometer.
4) Assess the surgical site.
Ah - these are the questions that seem to trip me up more often -- it's obviously 3 or 4... on one hand you want to assess the surgical site for hemorrhage since it's really too early for signs of infection to show up, but you must make sure that the patient can keep secretions clear and prevent atelectasis post-op.
If this were on an exam I was taking I would choose 3 - since it deals with airway and helps to ensure adequate gas exchange.
That was the reason that I posted my line of thinking when responding and also why I like the idea of this type of tread (practice questions)... especially since I am preparing for my exit HESI..
I have had very similar questions to this on practice questions and have learned that the inclusion or omission of even a single word changes the answer.. this is what I inferred from reading the question -- without trying to read anything into the question.
There is no information in this question as to weather this is immediately post op - the patient is still in PACU -- or if the patient was stable enough and has been transferred to the floor... but the question does imply that the patient is at the stage where learning to correctly use a spirometer is appropriate. Since I was taught that following surgery the surgeon is the one to make the first dressing change, the only real assessment here would be to observe the dressing for excessive bleeding.... That is why I would choose the airway answer first...
In the real world would you assess the extremity (assuming most ortho procedures are on extremities :) )first - pulse, sensation, excessively bloody bandage? well yes... but do you always do that at NCLEX memorial?
Would hemorrhage, hematoma, or thrombus kill you before lack of using IS?
Although adequate oxygenation is priority, this question does not state anything about this patient being in any kind of respiratory distress, and even if they were, and IS is not going to fix it.
Adequate oxygenation is multimodal. An IS is important after surgery but some patients don't even do it and are just fine.
I'd see #1 first. Everyone else is stable, while he is actively withdrawing which is NOT stable.
For the post-operative question, checking bowel sounds would be my priority. Lack of the return of bowel sounds after Surgery needs to be treated promptly.
Who cares about temporary bowel imobility especially if you're hospital has Relistor, colace? or potential atelectasis when you're bleeding out under the sheets or you have a dead leg?
Lev, MSN, RN, NP
4 Articles; 2,805 Posts
It's a question I made up. I think it's a good question and fairly straightforward as are most questions on NCLEX. Most people who responded came to the right conclusion as to the answer. I learned in nursing school that pain is the fifth vital sign. However, I learned in my NCLEX review course that pain is also considered psychosocial unless it is unexpected and therefore a sign of a new physiological process. The patient in sickle cell crisis is going to be in pain. Over a number of days, the pain gets better with oxygen, fluids, and sometimes blood transfusions and is relieved by narcotics. The pain is there and is a sign of the crisis. There is no indication in the question of the pain getting worse or being unrelieved.
The patient in alcohol withdrawal needs immediate attention. Have you ever seen a nasty case of SVT that happened as a result of untreated ETOH withdrawal. 107 is still high. Whether it's 107, 117, or 127 it's still tachycardia. It will be 107 one minute 127 the next if left untreated.
Tachycardia is stressful on the heart and increases myocardial oxygen demand. It's a circulation issue because it involves the heart. Even if it is a sign of alcohol withdrawal, it still has it's own physiological reason. Dehydration?
In real life, I would probably medicate my sickle cell patient first, unless my ETOH patient was very agitated.
However, not on NCLEX.