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.

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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.

A. Development of a buffalo hump and moon face B. Central obesity and purple striations C. Sudden weight loss without dieting D. Positive Trosseau's sign when checking the client's blood pressure

Correct Answer is C

Explanation

A. Development of a buffalo hump and moon face:
This is associated with Cushing's syndrome, a disorder characterized by prolonged exposure to high levels of cortisol.

B. Central obesity and purple striations:
Also indicative of Cushing's syndrome, where excess cortisol can lead to the accumulation of fat in the abdominal area (central obesity) and the development of purple stretch marks (striae).

C. Sudden weight loss without dieting:
This is more characteristic of hyperthyroidism, where the thyroid gland is overactive, leading to increased metabolism and unintended weight loss.

D. Positive Trousseau's sign when checking the client's blood pressure:
Trousseau's sign is associated with hypocalcemia and is seen in conditions affecting the parathyroid gland rather than the thyroid. It involves carpal spasm induced by inflating a blood pressure cuff above the systolic pressure for a few minutes.

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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?

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