# Stage 3 — Prioritize hypotheses. The 10-year-old child with sickle cell disease was admitted 12 hours ago for leg and back pain after poor oral intake. Leg pain is now 6/10 (9/10 at admission). The child has a temperature of 38.7 C, new cough, chest pain, RR 32/min, and SpO2 89% on room air (97% at admission). The child splints on inspiration, breath sounds are diminished at the right base, and the chest radiograph shows a new right lower-lobe infiltrate. Hemoglobin is 6.9 g/dL (baseline 8.4 g/dL) with an elevated reticulocyte count; the spleen is not palpable. The child drifts off mid-sentence since the third morphine dose. Complete the diagram by selecting the condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=617348&lang=en  
> language: en  
> subject: Establishing Priorities  
> category: MOC

## Question

Stage 3 — Prioritize hypotheses. The 10-year-old child with sickle cell disease was admitted 12 hours ago for leg and back pain after poor oral intake. Leg pain is now 6/10 (9/10 at admission). The child has a temperature of 38.7 C, new cough, chest pain, RR 32/min, and SpO2 89% on room air (97% at admission). The child splints on inspiration, breath sounds are diminished at the right base, and the chest radiograph shows a new right lower-lobe infiltrate. Hemoglobin is 6.9 g/dL (baseline 8.4 g/dL) with an elevated reticulocyte count; the spleen is not palpable. The child drifts off mid-sentence since the third morphine dose. Complete the diagram by selecting the condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Condition

Select 1
Opioid-induced hypoventilation
Splenic sequestration crisis
Vaso-occlusive chest wall pain
Acute chest syndrome

Actions to take

Select 2
Titrate oxygen to the prescribed goal
Keep the child on strict bed rest
Apply warm compresses over the painful chest wall
Give prescribed IV cephalosporin and macrolide
Prepare a weight-based heparin infusion

Parameters to monitor

Select 2
Spleen size on palpation
Oxygen saturation
Reticulocyte count
Hemoglobin level
Leg pain rating

## Explanation

A new pulmonary infiltrate with fever, cough, chest pain, and hypoxemia in a child with sickle cell disease is acute chest syndrome; the nonpalpable spleen argues against sequestration and the infiltrate cannot be explained by opioid sedation or chest-wall pain alone. Oxygen to the target saturation and prompt cephalosporin plus macrolide therapy address it now. Oxygen saturation and hemoglobin show whether the lung process and anemia are improving or progressing.

## In-depth explanation

Quick answer
Acute chest syndrome. Take action: titrate oxygen to the prescribed saturation goal and give IV cephalosporin plus a macrolide. Monitor: oxygen saturation and hemoglobin level.

Why this is correct
Acute chest syndrome is defined by a new infiltrate plus fever or respiratory findings, and it often starts during a pain admission. Hypoxemia is corrected immediately, and empiric antibiotics covering typical and atypical organisms are given because infection is a common trigger and these children have functional asplenia. The hemoglobin fall from 8.4 to 6.9 with a high reticulocyte count shows sickling and hemolysis in the lung; a further drop may require transfusion, so hemoglobin and saturation are the parameters that show progression.

Easy analogy or mental picture
Imagine sickled cells jamming the lung's small vessels like a traffic pile-up on a bridge: oxygen opens lanes, antibiotics clear the crash that started it, and the saturation and hemoglobin readings are the traffic report.

Memory hook
SICKLE + NEW INFILTRATE + FEVER = ACS: O2 and ANTIBIOTICS; watch SAT and HGB.

NCLEX decision rule
When a new finding (infiltrate) appears in a known chronic disease, name the complication it defines, then pick the parameters that would reveal its worsening.

Why the other choices are wrong
Opioid sedation lowers ventilation but does not cause fever or a new infiltrate; chest-wall vaso-occlusion causes splinting without consolidation; sequestration would enlarge the spleen, which is not palpable. Warm compresses treat chest-wall pain but not hypoxemia. Strict bed rest promotes atelectasis; incentive spirometry and mobilization are preferred. Heparin treats pulmonary embolism, which is not supported here. Spleen size tracks sequestration, the reticulocyte count tracks aplastic crisis, and leg pain tracks the original vaso-occlusive episode rather than lung response.

References
1Common Acute Complications of Sickle Cell DiseaseDefinition of acute chest syndrome, oxygen, antibiotics, incentive spirometry, and transfusion triggers
2NHLBI: Evidence-Based Management of Sickle Cell DiseaseEvidence-based management of acute chest syndrome in children with sickle cell disease

## Clinical scenario

Case update
The child remains tachypneic and hypoxemic with a new infiltrate and fever.

## Key concepts

- **Acute chest syndrome** — A new pulmonary infiltrate with fever or respiratory symptoms in sickle cell disease; a leading cause of death.
- **Functional asplenia** — Loss of splenic immune function from repeated infarction, raising the risk of serious bacterial infection.
- **Splenic sequestration** — Rapid pooling of blood in an enlarging spleen with an acute hemoglobin drop, most common in young children.

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