A patient is admitted with a diagnosis of sickle-cell crisis. The nurse assesses a temperature of 102° F, O2 saturation of 89%, and complaints of severe abdominal pain. Which prescription should the nurse implement first?
1. Give Tylenol (acetaminophen) 650 mg for elevated temperature.
2. Apply oxygen per nasal cannula at 3L/minute.
3. Administer morphine sulfate 4 mg IV.
4. Assess and document peripheral pulses.
2
Rationale 1: Although the temperature is elevated and will increase oxygen demands in the body by increased basal metabolic activity, this is not the first action the nurse should take.
Rationale 2: Hypoxia is often the cause of sickling crisis from the clumping of damaged RBCs, which creates an obstruction and hypoxia distal to the clumping. Administering oxygen will improve the pain and increase the oxygen saturation of body tissues.
Rationale 3: Morphine should be administered as soon as possible, but this is not the nurse's first action.
Rationale 4: A full body assessment, including peripheral pulses, is needed to identify the location of the potential obstruction, but this is not the nurse's primary action.
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