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 D
Explanation
Choice A reason: Metabolic acidosis is characterized by a decrease in blood pH (less than 7.35) due to a primary decrease in bicarbonate (HCO₃). The arterial blood gas results in this scenario do not indicate metabolic acidosis, as the pH is elevated and HCO₃ is within the normal range.
Choice B reason: Metabolic alkalosis is characterized by an increase in blood pH (greater than 7.45) due to a primary increase in bicarbonate (HCO₃). In this case, the pH is indeed elevated, but the bicarbonate level is normal, making this condition unlikely.
Choice C reason: Respiratory acidosis is characterized by a decrease in blood pH (less than 7.35) due to a primary increase in PaCO₂. The arterial blood gas results show an elevated pH and a decreased PaCO₂, which are not consistent with respiratory acidosis.
Choice D reason: Respiratory alkalosis is characterized by an increase in blood pH (greater than 7.45) due to a primary decrease in PaCO₂. In this scenario, the pH is elevated at 7.48, and the PaCO₂ is decreased at 32 mm Hg, indicating respiratory alkalosis. The bicarbonate level is within the normal range, further supporting this interpretation.
Correct Answer is A
Explanation
Reason: Blood sugar monitoring is a necessary intervention for patients with pancreatitis because the pancreas plays a critical role in regulating blood sugar levels through the production of insulin and glucagon. Inflammation or damage to the pancreas can lead to impaired insulin secretion and glucose metabolism, potentially causing hyperglycemia (high blood sugar levels). Therefore, monitoring blood sugar is essential to manage and prevent complications associated with pancreatitis.
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