A nurse is planning care for an adolescent client who has sickle cell anemia and is experiencing a vaso-occlusive crisis. Which of the following interventions is the nurse's priority?

Dose required per day = 50mg/kg/day × 40 kg = 2000 mg/day

Dose per administration = 2000mg4 doses= 500 mg/dose

Volume to administer:

200mg5ml=40mg/ml 

500mg40mg/ml=12.5ml/dose​

Correct answer =12.5mL/dose

A. Intake and output: The infant has not fed in 8 hours and has only had 1 wet diaper during this time, which is concerning for dehydration or inadequate intake. The decreased output requires immediate follow-up to prevent further dehydration and assess fluid needs.
B. Heart rate: The heart rate of 180/min is elevated for an infant, potentially indicating dehydration, fever, or respiratory distress. Tachycardia can also signify compensation for hypoxia.
C. Respiratory rate: A respiratory rate of 60/min is elevated for an infant and indicates respiratory distress, compounded by retractions and diminished lung sounds in the right lobes.
D. Bowel sounds: Active bowel sounds in all four quadrants are a normal finding and do not indicate an acute issue.
E. Mucous membranes: While dry mucous membranes confirm dehydration, they are not the highest priority compared to respiratory distress or oxygen saturation.
F. Weight: Weight loss from 9 lb to 8 lb 8 oz is concerning for chronic dehydration or inadequate nutrition, but it does not require immediate action compared to acute respiratory and oxygenation issues.
G. Retractions: Moderate substernal and intercostal retractions are indicative of respiratory distress. This requires immediate follow-up to assess the severity of the distress and initiate appropriate interventions, such as supplemental oxygen or further evaluation.
H. Lung sounds: Diminished lung sounds in the right lobes and occasional coarse crackles are concerning for a respiratory infection or condition such as pneumonia or bronchiolitis. Immediate follow-up is required to assess the cause and severity of the respiratory findings.
I. Temperature: The infant has a fever, which is concerning, especially with poor feeding and lethargy. Fever in an infant can indicate a serious infection (e.g., sepsis, urinary tract infection, or pneumonia) that requires immediate medical attention and further investigation.
J. Oxygen saturation: An oxygen saturation of 92% is low for an infant, indicating hypoxia, likely due to respiratory compromise. Immediate intervention (e.g., oxygen therapy) is necessary to prevent further deterioration.