The medical ICU to help out because there were several sick calls

 

Scenario #1

Question #1:

The data collection findings that should be reported to the RN immediately include blood oozing from the IV sites on the client’s left arm, tea-colored urine in the Foley catheter, and blood oozing from the central line site in the chest. These signs indicate potential complications such as IV infiltration, hematuria, and central line-associated bloodstream infection (CLABSI). Prompt reporting is crucial because these findings suggest a possible deterioration in the client’s condition, including vascular compromise, renal dysfunction, and infection. Timely intervention and assessment by the RN are necessary to address these issues and prevent further complications for the client.

Question #2:

Risk factors for Disseminated Intravascular Coagulation (DIC) in the client’s history include septic shock, presence of multiple invasive lines (IV sites, Foley catheter, central line), and the observation of bleeding from these sites. Septic shock can trigger DIC due to systemic inflammation and coagulation abnormalities. The presence of invasive lines increases the risk of infection and clot formation, which can lead to abnormal coagulation cascade activation seen in DIC. Bleeding from IV sites and central line suggests potential coagulopathy and consumption of clotting factors, further predisposing the client to DIC.

Scenario #2

Question #3:

The nurse should be concerned about the client’s knee pain in the context of hemophilia A. Hemophilia A is a bleeding disorder characterized by deficient or defective factor VIII, leading to impaired blood clotting. The sudden onset of severe knee pain without a history of trauma raises concerns for spontaneous bleeding into the joint (hemarthrosis), a common complication in individuals with hemophilia A. Untreated hemarthrosis can cause joint damage, pain, swelling, and limited range of motion. Prompt assessment and management of the knee pain are essential to prevent further joint complications and provide appropriate care for the client.

Question #4:

The vast majority of clients with hemophilia are male because hemophilia is an X-linked recessive genetic disorder. The gene for hemophilia is located on the X chromosome. Males have one X chromosome and one Y chromosome, so if they inherit an X chromosome with the hemophilia gene, they will have hemophilia. In contrast, females have two X chromosomes, so they need to inherit two copies of the defective gene to have hemophilia, making it less common in females. Therefore, males are more commonly affected by hemophilia due to their genetic makeup.

Scenario #3

Question #5:

The priority nursing intervention for the client with sickle cell disease presenting with severe pain (10/10) to her arms and chest is prompt pain management. Sickle cell disease is characterized by vaso-occlusive crises that can cause severe acute pain due to sickled red blood cells obstructing blood flow in small vessels. Immediate pain relief is essential to alleviate the client’s distress, prevent complications such as tissue damage or acute chest syndrome, and improve overall outcomes. The nurse should assess the pain intensity, administer analgesics as prescribed, monitor for pain relief efficacy, and provide supportive care to address the client’s pain and comfort needs effectively