A 36-year-old female presents at the clinic with symptoms of fatigue, palpitations, tinnitus, and excessive tiredness with activity.

These symptoms have gradually increased in severity over the last 2 months. The nurse suspects anemia.

For each statement, select whether it is consistent with Iron deficiency anemia, Vitamin B12 deficiency anemia, or Folic acid deficiency anemia.

Each statement can have more than one correct answer.

Choice A rationale
Testing the fluid on the dressing for glucose is the immediate action the nurse should take. Clear fluid could be cerebrospinal fluid (CSF), which is often released following spinal surgery. CSF contains glucose, so a positive glucose test would confirm it is CSF.
Choice B rationale
Replacing the dressing using a compression bandage is not the immediate action the nurse should take. While it is important to manage the drainage and prevent infection, the nurse first needs to identify what the clear fluid is.
Choice C rationale
Marking the drainage area with a pen and continuing to monitor is not the immediate action the nurse should take. While this can be part of ongoing wound care and monitoring, the nurse first needs to identify what the clear fluid is.

Choice D rationale
Documenting the findings in the electronic medical record is an important step, but it should not be the immediate action. The nurse first needs to identify what the clear fluid is, as it could indicate a complication from the surgery.

Choice A rationale
The absence of coarse crackles is not necessarily an indication that chest physiotherapy (CPT) has been effective for a client with chronic obstructive pulmonary disease (COPD). Coarse crackles are often heard in conditions where there is fluid in the airways, such as pneumonia or heart failure. While their absence might indicate that there is no fluid in the airways, it does not necessarily mean that secretions have been effectively mobilized.
Choice B rationale
An increase in breath sounds is a good indication that chest physiotherapy (CPT) has been effective for a client with COPD3. CPT is a group of therapies designed to improve respiratory efficiency, promote expansion of the lungs, strengthen respiratory muscles, and eliminate secretions from the respiratory system. When these secretions are effectively mobilized and removed, breath sounds can become clearer and more easily heard.
Choice C rationale

The absence of fine crackles is not necessarily an indication that CPT has been effective for a client with COPD. Fine crackles are often heard in conditions where there is fluid in the airways or alveoli, such as pneumonia or heart failure. While their absence might indicate that there is no fluid in the airways or alveoli, it does not necessarily mean that secretions have been effectively mobilized.
Choice D rationale
An increase in respiratory rate is not necessarily an indication that CPT has been effective for a client with COPD. In fact, an increased respiratory rate could indicate respiratory distress, which could suggest that the therapy has not been effective or that the client’s condition has worsened.