# 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?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=375010&lang=en  
> language: en  
> subject: NCLEX-RN  
> category: ROR

## 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?

## Option

1. Increase IV fluids to 2 times maintenance to improve perfusion
2. Prepare the client for emergent red blood cell exchange transfusion **✔ Correct answer**
3. Discontinue oxygen because elevated FiO2 worsens sickling
4. Switch from PCA opioids to oral acetaminophen alone

**Correct answer: 2**

## 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.

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