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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Free Nursing Study Resources

Correct Answer is D

Explanation

A. Flushed skin: Flushed or warm skin is more characteristic of hyperthyroidism, where there is an excess of thyroid hormones.

B. Palpitations: Palpitations or a rapid heartbeat are more characteristic of hyperthyroidism, where there is an excess of thyroid hormones.

C. Bulging eyes: Bulging or protruding eyes, known as exophthalmos, is a characteristic sign of Graves' disease, which is a specific type of hyperthyroidism.

D. Fatigue: This is correct. Fatigue is a common symptom of hypothyroidism, reflecting the overall slowing down of the body's processes.

A. IV administration of 50% dextrose in water B. IV bolus of 5% dextrose in 0.45% NaCI C. Administer 4 oz. clear juice D. Subcutaneous administration of 12 to 15 units of regular insulin

Correct Answer is A

Explanation

A. IV administration of 50% dextrose in water:
This is the correct answer. The client is severely hypoglycemic, and IV administration of 50% dextrose in water is the most rapid way to raise the blood glucose level in an emergency situation.

B. IV bolus of 5% dextrose in 0.45% NaCl:
While this solution contains dextrose, it is not as concentrated as 50% dextrose. In an emergency, a more concentrated solution is needed to rapidly correct severe hypoglycemia.

C. Administer 4 oz. clear juice:
Oral intake may be too slow in this critical situation. IV administration is more appropriate for rapidly raising the blood glucose level.

D. Subcutaneous administration of 12 to 15 units of regular insulin:
This would further lower the blood glucose level and is not appropriate for treating severe hypoglycemia.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient diagnosed with hypothyroidism. When assessing this patient, what sign or symptom would the nurse expect?

Correct Answer is D

Explanation

A client has been brought to the emergency department by paramedics after being found unconscious. The client's Medic Alert bracelet indicates that the client has type 1 diabetes and the client's blood glucose is 22 mg/dL (1.2 mmol/L). The nurse should anticipate what intervention?

Correct Answer is A

Explanation

The nurse is caring for a patient with Addison's disease who is scheduled for discharge. When teaching the patient about hormone replacement therapy, the nurse should address what topic?

Which of the following should be included in the teaching plan for a patient receiving glargine (Lantus), "peakless" basal insulin?

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 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 nurse is caring for a client who has hyperthyroidism. Which of the following manifestations should the nurse expect the client to report?

The nurse instructs the client about the self-administration of insulin. Which statement or statements by the patient indicate a need for further teaching? (SELECT ALL THAT APPLY)