# A 24-year-old client with sickle cell disease is receiving treatment for a vaso-occlusive pain episode. Eighteen hours after admission, the client develops a temperature of 39.1°C (102.4°F), cough, and increasing chest pain. Oxygen saturation has fallen from 96% to 88% on room air, hemoglobin from 8.4 to 6.9 g/dL, and a new right-lower-lobe infiltrate is present. Complete the bowtie by selecting the condition, two actions the nurse should take, and two parameters the nurse should monitor.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=604458&lang=en  
> language: en  
> subject: Illness Management  
> category: PA

## Question

A 24-year-old client with sickle cell disease is receiving treatment for a vaso-occlusive pain episode. Eighteen hours after admission, the client develops a temperature of 39.1°C (102.4°F), cough, and increasing chest pain. Oxygen saturation has fallen from 96% to 88% on room air, hemoglobin from 8.4 to 6.9 g/dL, and a new right-lower-lobe infiltrate is present. Complete the bowtie by selecting the condition, two actions the nurse should take, and two parameters the nurse should monitor.

Condition

Select 1
Acute chest syndrome
Pulmonary embolism
Uncomplicated vaso-occlusive pain episode
Opioid-induced respiratory depression

Actions to take

Select 2
Apply oxygen, begin continuous pulse oximetry, and activate urgent clinical escalation
Prepare prescribed empiric antibiotics and urgent transfusion evaluation while supportive care continues
Start therapeutic anticoagulation before further assessment
Increase the opioid dose and reassess oxygenation at the next routine round
Wait for sputum culture results before beginning additional therapy

Parameters to monitor

Select 2
International normalized ratio after warfarin therapy
Oxygen saturation and work of breathing
Daily calf circumference on the painful extremity
Hemoglobin trend and response to transfusion therapy
Urine ketones and serum beta-hydroxybutyrate

## Explanation

The new pulmonary infiltrate with fever, cough, progressive hypoxemia, and falling hemoglobin supports acute chest syndrome. Immediate oxygenation support, urgent escalation, antibiotics, and transfusion evaluation are priorities; oxygenation and hemoglobin trends show whether therapy is working.

## In-depth explanation

Correct answer
Acute chest syndrome; oxygen with urgent escalation; antibiotics with transfusion evaluation; monitor oxygenation and hemoglobin response.
Why it fits
A new infiltrate plus fever or respiratory symptoms in sickle cell disease supports acute chest syndrome. The falling oxygen saturation and hemoglobin indicate progression rather than an uncomplicated pain episode.
Action rationale
Hypoxemia is treated immediately while the nurse escalates care. Empiric antibiotics and transfusion evaluation proceed without waiting for culture results when acute chest syndrome is suspected.
Monitoring rationale
Oxygen saturation and work of breathing track respiratory response. Serial hemoglobin and transfusion response track worsening anemia and the effect of transfusion support.
NCLEX rule
Choose actions that address the immediate physiologic threat, then choose parameters that directly show whether those actions are effective.
Why the alternatives fail
Anticoagulation targets pulmonary embolism, delayed reassessment is unsafe, and culture delay postpones time-sensitive treatment. INR, calf size, and ketones do not measure response to acute chest syndrome therapy.
**Sources**
- American Society of Hematology — Sickle Cell Disease ER Checklist

- American Society of Hematology — SCD Transfusion Support

## Key concepts

- **Acute chest syndrome** — A sickle cell complication characterized by a new pulmonary infiltrate with respiratory signs or symptoms.
- **Transfusion evaluation** — Urgent assessment of whether simple or exchange transfusion is needed for severe anemia or respiratory compromise.

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