A 22-year-old with sickle cell disease in a vaso-occlusive c… | MyMerci
NCLEX-RNROR
Question
A 22-year-old with sickle cell disease in a vaso-occlusive crisis becomes increasingly hypoxic with new bilateral pulmonary infiltrates. Which intervention should the nurse anticipate as a top priority?
1Increase IV fluids to 2 times maintenance to improve perfusion
2Prepare the client for emergent red blood cell exchange transfusion✓ Correct answer
3Discontinue oxygen because elevated FiO2 worsens sickling
4Switch from PCA opioids to oral acetaminophen alone
Explanation
Severe acute chest syndrome (worsening hypoxia, new infiltrates, multilobar disease) is treated with red blood cell EXCHANGE transfusion to rapidly reduce HbS percentage below 30 — simple transfusion is used in mild ACS. ACS is the leading cause of mortality in adult sickle cell disease. Over-hydration above 1 to 1.5 times maintenance worsens pulmonary edema. Oxygen is targeted to baseline saturation, not removed. Adequate analgesia must continue.
In-depth explanation
ACS triad: new infiltrate + fever + respiratory symptoms. Exchange transfusion target: HbS under 30, Hb 10-11 to avoid hyperviscosity.
Clinical scenario
Hospital day 2 for VOC. SpO2 has dropped from 95 to 84 percent on 6 L NC over 2 hours. New cough, RR 32, temp 38.6 C. CXR shows new bilateral lower lobe infiltrates.
Key concepts
acute chest syndrome — New pulmonary infiltrate with respiratory symptoms in SCD; medical emergency.
exchange transfusion — Removal of patient blood with replacement of donor RBCs; rapidly reduces HbS percentage.
hyperviscosity — Increased blood thickness from over-transfusion; risk of stroke in SCD.