A client is being treated on the medical unit for a sickle cell crisis. The nurse's most recent assessment reveals an oral temperature of 100.5°F and a new onset of fine crackles on lung auscultation. What is the nurse's most appropriate action?
Liaise with the respiratory therapist and consider high flow oxygen.
Inform the primary care provider that the patient may have an infection.
Apply supplementary oxygen by nasal cannula.
Administer bronchodilators by nebulizer.
The Correct Answer is B
A. Inform the primary care provider that the patient may have an infection:
Explanation: The presence of an elevated oral temperature and new onset of fine crackles on lung auscultation suggests a potential respiratory infection, which is a significant concern in a patient with sickle cell disease. Notifying the primary care provider allows for further evaluation and appropriate management of the infection.
B. Liaise with the respiratory therapist and consider high-flow oxygen:
Explanation: While oxygenation may be necessary, especially if the patient is experiencing respiratory distress, addressing the potential infection is the priority. Consulting with the respiratory therapist and considering high-flow oxygen can be part of the overall plan based on the primary care provider's recommendations.
C. Apply supplementary oxygen by nasal cannula:
Explanation: Providing oxygen support may be necessary, but it should be done in consultation with the primary care provider, who can guide the appropriate level of oxygen therapy based on the patient's condition.
D. Administer bronchodilators by nebulizer:
Explanation: Bronchodilators are typically used for conditions like asthma or COPD, and their use might not be the primary intervention in the context of a sickle cell crisis with signs of a potential respiratory infection. Addressing the infection takes precedence, and the primary care provider's input is essential in determining the appropriate course of action.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. pH 7.28, pCO2 36, HCO3 23:
Explanation: The pH is low, indicating acidosis. However, the pCO2 is within the normal range, which is not consistent with respiratory acidosis. The HCO3 is slightly low but not significantly, and this doesn't align with typical findings in respiratory acidosis.
B. pH 7.52, pCO2 28, HCO3 25:
Explanation: The pH is high, indicating alkalosis. The pCO2 is below the normal range, which is not consistent with respiratory acidosis. The HCO3 is within the normal range, and these values are not typical for respiratory acidosis.
C. pH 7.25, pCO2 50, HCO3 22:
Explanation: The pH is low, indicating acidosis. The pCO2 is elevated, which is typical in respiratory acidosis. The HCO3 is within the normal range, suggesting uncompensated respiratory acidosis.
D. pH 7.35, pCO2 40, HCO3 24:
Explanation: The pH is within the normal range, and both pCO2 and HCO3 are normal. These values do not indicate acidosis.
Correct Answer is C
Explanation
A. "I will make sure I call the diabetes educator each time I adjust my insulin dose."
This statement suggests a reliance on insulin adjustment and implies frequent contact with the diabetes educator. However, it doesn't address the primary treatment for type 2 diabetes.
B. "I read that a pancreas transplant will provide a cure for my diabetes."
This statement mentions a pancreas transplant, which is a significant and rare intervention typically reserved for severe cases of diabetes. However, it's not considered the primary treatment for type 2 diabetes.
C. "I will make sure to follow the weight loss plan designed by the dietitian."
This statement aligns with a key aspect of managing type 2 diabetes, as weight management, along with diet and exercise, is a primary approach. Lifestyle modifications, including weight loss, are often part of the primary treatment plan.
D. "I will take my oral anti-diabetic agents when my morning blood sugar is high."
This statement indicates an understanding of the importance of oral anti-diabetic agents, which are commonly used in the management of type 2 diabetes. Timing medication based on blood sugar levels is a key aspect of treatment.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today