A female client with iron-deficiency anemia is experiencing increased fatigue and a shiny red tongue. The nurse would anticipate seeing which additional assessment finding(s) (SELECT ALL THAT APPLY)

Bottle spoon-shaped finger nails

Platelets 400.000/0

Rea blood cell count 4.5 million/mm3

Hemoglobin 8.0 g/di

Tachypnea

Answer and Explanation

Correct Answer : A,D,E

A. Bottle spoon-shaped fingernails: This is a classic sign associated with iron deficiency anemia, known as koilonychia. The nails may appear thin, brittle, and spoon-shaped, indicating a deficiency in iron.

B. Platelets 400,000/µL: This platelet count is within the normal range (typically 150,000 to 450,000/µL) and does not specifically indicate iron deficiency anemia. Thus, it is not an expected finding.

C. Red blood cell count 4.5 million/mm³: This value is within the normal range for females (approximately 4.2 to 5.4 million/mm³). In iron deficiency anemia, one would expect the RBC count to be low or at least on the lower end of normal.

D. Hemoglobin 8.0 g/dL: This low hemoglobin level is indicative of anemia. In iron deficiency anemia, hemoglobin levels are often significantly decreased, so this finding aligns with the client's condition.

E. Tachypnea: Increased respiratory rate can occur in response to anemia, as the body attempts to compensate for decreased oxygen-carrying capacity by increasing breathing rate. Therefore, tachypnea is a likely finding in this client.

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Correct Answer is A

Explanation

A) Maintain IV fluid infusion and assess adequacy of hydration: This is the best nursing action as adequate hydration is crucial in managing sickle cell crisis. It helps to reduce blood viscosity and prevent further sickling of red blood cells, which is especially important in the context of pneumonia, as dehydration can exacerbate the crisis.

B) Provide continuous sedation for pain relief: While managing pain is essential, continuous sedation is not the most appropriate first step in this situation. Pain management should be addressed, but hydration and treating the underlying causes (like pneumonia) take priority.

C) Insert an indwelling (Foley) catheter and monitor hourly urinary output: While monitoring urinary output can be important, it is not the most immediate action in this case. Focus should be on hydration and addressing the sickle cell crisis rather than on urinary output at this time.

D) Prepare for endotracheal intubation and ventilatory support: Although respiratory distress is a concern with pneumonia, the current pulse oximetry reading of 96% indicates adequate oxygenation at this time. Preparing for intubation should not be the first action unless the patient shows signs of respiratory failure or severe distress.

A. has gained 2 pounds and has pink buccal mucosa. B. verbalizes eating more iron fortified cereals. C. no longer has paresthesia of the hands and feet. D. has stopped drinking any alcoholic beverages

Correct Answer is C

Explanation

A) Has gained 2 pounds and has pink buccal mucosa: While weight gain and pink mucosa are positive signs, they are not definitive indicators of effective treatment for Vitamin B12 deficiency specifically.

B) Verbalizes eating more iron-fortified cereals: This dietary change is beneficial for overall nutrition but does not directly relate to the treatment of Vitamin B12 deficiency. Iron and Vitamin B12 serve different functions in the body.

C) No longer has paresthesia of the hands and feet: The resolution of paresthesia is a strong indicator that the treatment for Vitamin B12 deficiency has been effective. Paresthesia is often associated with nerve damage due to B12 deficiency, so its absence suggests improvement.

D) Has stopped drinking any alcoholic beverages: While reducing alcohol intake can be beneficial for overall health and may help with nutrient absorption, this change alone does
not indicate that the specific treatment for Vitamin B12 deficiency has been effective.

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A female client with iron-deficiency anemia is experiencing increased fatigue and a shiny red tongue. The nurse would anticipate seeing which additional assessment finding(s) (SELECT ALL THAT APPLY)

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Naxlex Comprehensive Predictor Exams

A client is experiencing sickle cell crisis precipitated by a right lower lobe pneumonia. The vital signs are: HR-110/min: RR-28; B/P-96/54: T-100.8 PO: Pulse Oximetry-96%. What is the best nursing action?

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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