hard · NCLEX-RN Physiological Adaptation
A 2-year-old client with sickle cell disease (HbSS) is admitted to the pediatric unit with acute splenic sequestration crisis and severe hypovolemic shock. Which actions should the nurse include in the immediate plan of care? Select all that apply.
- Prepare the client and family for potential emergent splenectomy.
- Perform deep abdominal palpation of the left upper quadrant every hour to monitor spleen size.
- Administer immediate intravenous boluses of 0.9% sodium chloride as prescribed.
- Administer high-dose intramuscular analgesics in the gluteus maximus for abdominal pain.
- Transfuse packed red blood cells slowly to target a hemoglobin no higher than 8 to 9 g/dL.
- Position the client flat on their back without elevation to promote venous return.
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