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 ["C","D"]
Explanation
Choice A reason: Placing the patient in restraints for safety is not typically necessary unless the patient is agitated or a danger to themselves or others. This action is not directly addressing the acute condition of a stroke.
Choice B reason: Inserting an NGT (nasogastric tube) is not an immediate priority in the acute management of a stroke. This might be considered later if the patient has swallowing difficulties and needs nutritional support, but it is not a first-line intervention.
Choice C reason: Anticipating thrombolytic therapy for ischemic stroke is appropriate, as timely administration of thrombolytics can dissolve the clot and improve blood flow to the affected brain area, potentially reducing the severity of the stroke.
Choice D reason: Establishing IV access with normal saline is crucial for administering medications and maintaining hydration. It ensures that the patient can receive necessary interventions promptly.
Choice E reason: Placing the patient in the prone position is not appropriate in the management of an acute stroke. The prone position is generally used in respiratory conditions to improve oxygenation but is not relevant to stroke management.
Correct Answer is A
Explanation
Reason: Emotional distress can indeed decrease treatment adherence. Patients experiencing high levels of emotional distress, such as anxiety, depression, or fear, may find it challenging to follow their treatment regimens consistently. This can result in missed appointments, skipped medications, and overall reduced compliance with their healthcare plan. Emotional support and mental health interventions are crucial for improving adherence and overall treatment outcomes.
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