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.

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

A. Metabolic Acidosis
Metabolic acidosis is characterized by a low pH and low bicarbonate (HCO3) level. In this case, the pH is low (indicating acidosis), but the bicarbonate level is within the normal range, which is inconsistent with metabolic acidosis.

B. Respiratory Acidosis
This is correct. Respiratory acidosis is characterized by an elevated partial pressure of carbon dioxide (PaCO2), leading to a decrease in pH. The ABG values in this case indicate elevated PaCO2 and a low pH, consistent with respiratory acidosis.

C. Metabolic Alkalosis
Metabolic alkalosis is characterized by a high pH and high bicarbonate (HCO3) level. In this case, the pH is low (indicating acidosis), which is inconsistent with metabolic alkalosis.

D. Respiratory Alkalosis
Respiratory alkalosis is characterized by a low partial pressure of carbon dioxide (PaCO2) and a high pH. In this case, the PaCO2 is elevated, which is inconsistent with respiratory alkalosis.

A. "Diet, exercise and oral medications can be effective. I will ask the physician to prescribe Metformin" B. "Your body does not produce insulin, and the only treatment is injected insulin" C. "Glucophage can help your body better utilize the insulin secreted by the pancreas" D. "Initially, you will need injections, but after your body adjusts to the insulin, you can switch to Metformin"

Correct Answer is B

Explanation

A. "Diet, exercise, and oral medications can be effective. I will ask the physician to prescribe Metformin":
Explanation: This statement is not accurate for type 1 diabetes. Type 1 diabetes results from the inability of the pancreas to produce insulin, so oral medications like Metformin, which work to increase insulin sensitivity or reduce glucose production in the liver, are not effective. Insulin replacement is the mainstay of treatment for type 1 diabetes.

B. "Your body does not produce insulin, and the only treatment is injected insulin":
Explanation: This is the correct statement. In type 1 diabetes, the pancreas does not produce insulin or produces very little, and insulin cannot be taken orally because it would be broken down in the digestive system. Therefore, injections are the primary and necessary mode of insulin delivery.

C. "Glucophage can help your body better utilize the insulin secreted by the pancreas":
Explanation: This statement is more applicable to type 2 diabetes, where the pancreas may still produce insulin, but the body's cells are resistant to its effects. In type 1 diabetes, the issue is a lack of insulin production, so medications to improve insulin utilization are not relevant.

D. "Initially, you will need injections, but after your body adjusts to the insulin, you can switch to Metformin":
Explanation: This is not accurate for type 1 diabetes. The need for insulin in type 1 diabetes is not something the body adjusts to over time. Insulin is a lifelong requirement for individuals with type 1 diabetes, and it cannot be replaced by oral medications like Metformin.

View Question and Answer

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

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse reviews the arterial blood gas (ABG) values of a client admitted with pneumonia: pH, 7.32; PaCO2, 48 mm Hg; PaO2, 70 mm Hg; and HCO3, 24 mEq/L. What do these values indicate?

Correct Answer is B

Explanation

A client diagnosed with type 1 diabetes states he is not comfortable with self-injections and asks the nurse if oral an anti- diabetic agent can be prescribed instead. Which of the following responses from the nurse is appropriate?

Correct Answer is B

Explanation

A client with Cushing's syndrome is receiving education about dietary changes from the nurse. Which statement by the patient demonstrates the need for further teaching?

A patient with a longstanding diagnosis of generalized anxiety disorder presents to the emergency room. The triage nurse notes upon an assessment that the patient is hyperventilating. The triage nurse is aware that hyperventilation is the MOST common cause of which acid-base imbalance?

A patient is post-op from knee surgery. The patient has been receiving Morphine 4 mg IV every 2 hours. The nurse notices the patient is exhibiting a respiratory rate of 8 and is extremely drowsy. Which of the following conditions is the patient at risk for?

The nurse is discussing macrovascular complications of diabetes with a client. The nurse would address what topic during this dialogue?

The nurse understands causes of respiratory acidosis include: (SELECT ALL THAT APPLY)

A client with diabetes mellitus is ordered to receive insulin for glucose correction (sliding scale coverage). The nurse knows the rapid acting insulin Insulin Lispro (Humalog) onset and peak action time are:

A nursing instructor is evaluating a student caring for a neutropenic client. The instructor concludes that the nursing student demonstrates accurate knowledge of neutropenia based on which of the following interventions?