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 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. Respiratory acidosis B. Metabolic acidosis C. Respiratory alkalosis D. Metabolic alkalosis

Correct Answer is D

Explanation

A. Respiratory acidosis:
This occurs when there is inadequate ventilation, leading to an accumulation of carbon dioxide (CO2) in the blood. In the context of a nasogastric tube attached to low suction, respiratory acidosis is not the primary concern. It is more associated with conditions like respiratory depression or lung diseases.

B. Metabolic acidosis:
Metabolic acidosis results from an excess of acid or a loss of bicarbonate. It is not the typical outcome of a nasogastric tube attached to low suction. Conditions like diarrhea or renal failure are more commonly associated with metabolic acidosis.

C. Respiratory alkalosis:
Respiratory alkalosis occurs when there is excessive loss of carbon dioxide from the body, often due to hyperventilation. This is not a typical consequence of a nasogastric tube attached to low suction.

D. Metabolic alkalosis:
Metabolic alkalosis is characterized by an excess of bicarbonate or a loss of acid. In the given context, with the nasogastric tube attached to low suction, there is a potential loss of gastric acid, contributing to metabolic alkalosis.

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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

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

The nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client for manifestations of which disorder that the client is at risk for?

Correct Answer is D

Explanation

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