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: Hypotension, chills, and thirst are not characteristic signs and symptoms of a thyroid storm. Hypotension generally indicates low blood pressure, while chills and thirst are less specific symptoms that do not particularly point to thyroid storm.
Choice B reason: Lethargy, confusion, and bradycardia are not typical indicators of a thyroid storm. These symptoms might be present in other conditions but are not generally associated with the severe hypermetabolic state seen in thyroid storms.
Choice C reason: Bradycardia, hypotension, and low urine output are also not typical signs of a thyroid storm. Bradycardia (slow heart rate) and hypotension (low blood pressure) are more likely associated with severe hypothyroidism or other conditions, not the hyperactive state of a thyroid storm.
Choice D reason: Fever, tachycardia, and tremors are classic signs of a thyroid storm. A thyroid storm is a life-threatening condition characterized by an excessive amount of thyroid hormones, leading to hypermetabolic activity. This results in symptoms like a high fever, rapid heart rate (tachycardia), and tremors.
Correct Answer is C
Explanation
Choice A reason: Endocardial infection is not commonly associated with Alzheimer's disease. While it can occur, it is not a frequent infection related to chronic dementia.
Choice B reason: Brain infections, such as encephalitis, can occur but are not among the most common infections seen in patients with Alzheimer's disease.
Choice C reason: Urinary tract infections (UTIs) are common in patients with Alzheimer's disease due to factors such as immobility, incontinence, and the use of catheters. UTIs can exacerbate confusion and other dementia-related symptoms.
Choice D reason: Pneumonia is a common and serious infection in patients with Alzheimer's disease. Due to cognitive impairment, these patients may have difficulty swallowing, leading to aspiration pneumonia. Additionally, their weakened immune systems make them more susceptible to respiratory infections.
Choice E reason: Gastrointestinal infections are not typically associated with Alzheimer's disease as a common complication. While they can occur, they are not as prevalent as UTIs and pneumonia in this patient population.
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