# Stage 5 — Take action. Three hours after acute chest syndrome treatment began, the child's SpO2 is 89% on 4 L/min of oxygen, RR is 38/min with intercostal retractions, and hemoglobin is 6.2 g/dL (6.9 g/dL three hours ago). The child has a sedation score of 3 (frequently drowsy, drifts off mid-sentence) and rates chest pain 8/10. Creatinine is 0.4 mg/dL and platelets are 310,000/mm3. Some active orders were written on admission for the leg and back pain crisis. Categorize each action by how the nurse should handle it now. > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=617248&lang=en > language: en > subject: Accident/Error/Injury Prevention > category: SIPC ## Question Stage 5 — Take action. Three hours after acute chest syndrome treatment began, the child's SpO2 is 89% on 4 L/min of oxygen, RR is 38/min with intercostal retractions, and hemoglobin is 6.2 g/dL (6.9 g/dL three hours ago). The child has a sedation score of 3 (frequently drowsy, drifts off mid-sentence) and rates chest pain 8/10. Creatinine is 0.4 mg/dL and platelets are 310,000/mm3. Some active orders were written on admission for the leg and back pain crisis. Categorize each action by how the nurse should handle it now. **1.** Titrate oxygen within the prescribed range to reach the saturation goal Select a category Carry out now under the active orders Escalate for an urgent change in the level of care Hold and clarify the order with the prescriber first **2.** Give the scheduled intravenous ketorolac dose Select a category Carry out now under the active orders Escalate for an urgent change in the level of care Hold and clarify the order with the prescriber first **3.** Send the ordered antigen-matched type and crossmatch sample Select a category Carry out now under the active orders Escalate for an urgent change in the level of care Hold and clarify the order with the prescriber first **4.** Continue intravenous fluid at 1.5 times maintenance as written on admission Select a category Carry out now under the active orders Escalate for an urgent change in the level of care Hold and clarify the order with the prescriber first **5.** Give the PRN intravenous morphine dose now due for chest pain Select a category Carry out now under the active orders Escalate for an urgent change in the level of care Hold and clarify the order with the prescriber first **6.** Apply the ice packs to the lower back listed in the admission comfort orders Select a category Carry out now under the active orders Escalate for an urgent change in the level of care Hold and clarify the order with the prescriber first **7.** Request urgent bedside evaluation by the pediatric critical-care team Select a category Carry out now under the active orders Escalate for an urgent change in the level of care Hold and clarify the order with the prescriber first **8.** Report the hemoglobin of 6.2 g/dL and rising oxygen need to hematology now Select a category Carry out now under the active orders Escalate for an urgent change in the level of care Hold and clarify the order with the prescriber first ## Explanation Oxygen titration, the nonopioid ketorolac dose (normal creatinine and platelets), and the antigen-matched crossmatch proceed now. The admission hyperhydration rate, the PRN morphine at a sedation score of 3, and cold packs conflict with acute chest syndrome care and need clarification. Rising oxygen need with retractions and a falling hemoglobin are signs of progression that require critical-care and hematology escalation for transfusion decisions, not another routine reassessment. ## In-depth explanation Quick answer Proceed: oxygen titration, scheduled ketorolac, antigen-matched crossmatch. Clarify: 1.5x maintenance fluid, PRN morphine, ice packs. Escalate: critical-care bedside evaluation and hematology notification. Why this is correct Each order must be re-checked against the current picture, not the admission diagnosis. The child now has acute chest syndrome with worsening hypoxemia, so fluids written to hyperhydrate a pain crisis risk pulmonary edema, and cold causes vasoconstriction that promotes sickling. A sedation score of 3 means the next opioid dose can deepen hypoventilation even though the respiratory rate is high, so morphine is held and clarified while the nonopioid part of multimodal analgesia (ketorolac, with normal renal function and platelets) continues to treat splinting pain. Preparing antigen-matched blood now avoids delay if transfusion is chosen. The combination of rising oxygen requirement, retractions, and a falling hemoglobin signals progression that needs a higher level of care. Easy analogy or mental picture Think of the admission orders as a map drawn for a different road: the child has changed routes, so each old instruction must be checked against the new road before you follow it. Memory hook "New diagnosis, re-read old orders" and "POSS 3 = pause the opioid, keep the nonopioid." NCLEX decision rule When a client's condition changes, orders written for the earlier condition are clarified before being carried out; deterioration in oxygenation plus falling hemoglobin in acute chest syndrome is escalated immediately. Why the other choices are wrong Continuing 1.5x maintenance fluid is tempting because hydration is taught for vaso-occlusive crises, but in acute chest syndrome excess fluid worsens lung injury. Giving the due morphine is tempting because pain is 8/10 and the respiratory rate is not low, but sedation precedes respiratory depression and splinting pain can be treated with the nonopioid component. Ice packs feel like standard comfort care, yet cold promotes sickling. Ketorolac may look risky, but renal function and platelets are normal, so it proceeds. The crossmatch is not premature; waiting delays transfusion. Escalation items are not simple clarifications: the problem is the child's trajectory, not a single order. References 1NHLBI: Evidence-Based Management of Sickle Cell Disease (Expert Panel Report)Acute chest syndrome definition, oxygen, antibiotics, incentive spirometry, cautious fluids, transfusion; fever as an emergency in SCD 2American Society of Hematology: Sickle Cell Disease GuidelinesPain management with opioid monitoring and multimodal analgesia; transfusion support and extended antigen matching ## Clinical scenario Case update Three hours into treatment the child needs more oxygen, has retractions, a further hemoglobin fall, and increasing sedation while several older orders remain active. ## Key concepts - **Acute chest syndrome** — A sickle cell complication with a new pulmonary infiltrate plus respiratory symptoms, chest pain, or fever that can progress rapidly to respiratory failure. - **Pasero Opioid-induced Sedation Scale** — A sedation scale on which a score of 3 (frequently drowsy, drifts off to sleep during conversation) calls for holding opioids and reassessing. - **Extended red-cell antigen matching** — Matching donor blood for C, E, and K antigens in sickle cell disease to reduce alloimmunization and delayed hemolytic reactions. ## Related questions - [A circulating nurse leads the final time-out for an operative procedure. 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