A client is being treated in the medical unit for a sickle cell crisis. The nurse's most recent assessment reveals a new onset of fever and fine crackles on lung auscultation. What is the nurse's most appropriate action?
Administer bronchodilators by nebulizer
Inform the health care provider that the client may have an infection
Apply supplementary oxygen by nasal cannula
Consult with the respiratory therapist and consider high-flow oxygen
The Correct Answer is B
A. Bronchodilators are not typically indicated unless the client also has a reactive airway component such as asthma; they do not treat infection.
B. A new onset of fever and crackles in a client with sickle cell crisis raises concern for acute chest syndrome, a life-threatening complication often triggered by infection. Promptly informing the healthcare provider is the most appropriate action to initiate further diagnostic workup and treatment (e.g., antibiotics, imaging).
C. While supplemental oxygen may be needed, the first action should be to notify the provider to assess for infection and initiate appropriate treatment.
D. High-flow oxygen may be necessary in severe cases, but this decision is made after medical evaluation — not the nurse’s first independent action.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Education is important but not a priority when the patient is experiencing acute symptoms such as worsening dyspnea and edema.
B. Drawing blood for BNP and electrolytes is part of the diagnostic process but does not immediately relieve symptoms or prevent complications.
C. Administering furosemide IV push addresses the most immediate concern: relieving fluid overload, which is causing dyspnea, orthopnea, and edema. It reduces preload and improves breathing, making it the priority action.
D. Continuous cardiac monitoring is appropriate, especially for a patient with heart failure, but relieving fluid overload takes precedence to stabilize the patient’s respiratory status.
Correct Answer is C
Explanation
A. Waiting two hours after eating before exercising helps prevent fatigue or gastrointestinal discomfort and is an appropriate strategy.
B. Starting with a warm-up activity helps prepare the body for exercise and is recommended, especially in clients with heart failure.
C. Exercising in extreme temperatures (hot or cold) can place additional stress on the cardiovascular system and is not safe for clients with heart failure. This statement indicates a need for further teaching.
D. Stopping exercise if experiencing shortness of breath or dizziness is an appropriate and safe practice.
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