A patient with sickle cell disease has developed cellulitis above the left ankle. Which action is the nurse's priority for this patient?
Administer antibiotics
Start IV fluids
Assess pain every 4 hours
Maintain oxygenation
The Correct Answer is D
Choice A reason: Administering antibiotics is essential for treating cellulitis to eliminate the infection. However, it is not the immediate priority over maintaining oxygenation, especially in a patient with sickle cell disease.
Choice B reason: Starting IV fluids is crucial for preventing dehydration and helping to reduce the sickling of red blood cells. Nevertheless, while important, it is not the most urgent action compared to maintaining adequate oxygen levels.
Choice C reason: Assessing pain every 4 hours is necessary for managing the patient's comfort and monitoring the progression of the disease. Although pain management is a significant aspect of care, it is not the top priority in this scenario.
Choice D reason: Maintaining oxygenation is the highest priority for a patient with sickle cell disease. These patients are at increased risk for hypoxia, which can exacerbate the sickling of red blood cells, leading to severe complications such as acute chest syndrome or stroke. Ensuring adequate oxygenation helps to prevent these complications and stabilizes the patient's condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Preventing DVT and VTE is a critical component of patient care in hospitals. These conditions can lead to serious complications such as pulmonary embolism, which can be life-threatening. Therefore, hospitals implement various measures, including the use of anticoagulants, compression devices, and early mobilization, to reduce the risk of DVT and VTE in hospitalized patients.
Choice B reason: The statement that DVT and VTE prevention is not a core measure for hospitalized patients is incorrect. Ensuring that patients are protected against these potential complications is a fundamental aspect of inpatient care to promote patient safety and improve outcomes.
Correct Answer is B
Explanation
Choice A reason: Checking the patient's temperature is important for assessing the severity of the pneumonia and monitoring for fever, but it is not the priority action before administering the first dose of vancomycin.
Choice B reason: Obtaining sputum cultures is the priority action because it allows for the identification of the causative organism and determination of its antibiotic susceptibility. This helps ensure that the prescribed antibiotic is appropriate for the patient's infection. Cultures should be obtained before starting antibiotic therapy to avoid interference with culture results.
Choice C reason: Checking the patient's blood pressure is important for overall patient assessment and monitoring, especially considering potential side effects of vancomycin. However, it is not the primary action needed before the first dose of the antibiotic.
Choice D reason: Drawing a blood specimen to evaluate the white blood cell count is useful for assessing the severity of the infection and the patient's immune response. However, this can be done after obtaining the sputum cultures and is not the immediate priority before administering the antibiotic.
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