A nurse in a provider's office is caring for a client.
Complete the following sentence by using the lists of options.
The first action the nurse should take is
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}
The first action the nurse should take is assess for dizziness when standing followed by increase dietary iron intake.
Rationale:
Assess for dizziness when standing: The client’s orthostatic hypotension (BP drops from 132/60 to 102/50 mmHg upon standing) and tachycardia (HR 108/min) suggest possible symptomatic anemia. Evaluating for dizziness ensures client safety and helps determine the severity of anemia-related hypoxia.
Increase dietary iron intake: The client has iron deficiency anemia (low hemoglobin, hematocrit, RBC count, and ferritin). Since they follow a vegan diet, increasing plant-based iron sources (e.g., leafy greens, legumes, fortified cereals) and vitamin C intake can improve iron absorption.
Incorrect:
Administer IV fluids: While anemia can cause orthostatic hypotension, fluid resuscitation is not the first-line intervention unless dehydration is present.
Check for signs of bleeding: The client reports no pain or discomfort, and there is no evidence of active bleeding. Anemia is more likely due to chronic dietary deficiency rather than acute blood loss.
Administer vitamin B12 supplements: The client’s vitamin B12 level is slightly low but not critically deficient. The primary issue is iron deficiency, not pernicious anemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Apply an ice pack to the client's knee: Ice application helps reduce pain and inflammation by decreasing swelling around the surgical site. Cold therapy also numbs nerve endings, providing pain relief for clients after knee arthroplasty.
B. Place pillows under the client's knee: Elevating the knee with pillows can promote flexion contractures and is generally avoided after knee arthroplasty. Instead, the leg should be kept extended and supported to encourage proper alignment and prevent complications.
C. Perform range-of-motion exercises to the client's knee: While range-of-motion exercises are important for rehabilitation, they should be done at scheduled times and not during episodes of acute pain, as they could exacerbate discomfort.
D. Gently massage the area around the client's incision: Massaging near the incision site is not recommended, as it could disrupt healing tissue, increase pain, and pose a risk of infection.
Correct Answer is D
Explanation
A. "I should use a heating pad when my feet are cold.": Clients with diabetes mellitus may have reduced sensation due to peripheral neuropathy. Using a heating pad increases the risk of burns or injury due to the inability to perceive excessive heat.
B. "I should plan to remain barefoot while I am at home.": Walking barefoot increases the risk of foot injuries, which can lead to infections and complications such as diabetic ulcers. Clients should always wear well-fitting shoes, even at home, to protect their feet.
C. "I should apply lotion between my toes twice a day.": Moisturizing the feet is important to prevent dryness and cracking, but applying lotion between the toes can create excess moisture, increasing the risk of fungal infections.
D. "I should file the edges of my toenails after trimming them.": Filing the edges helps smooth sharp corners, reducing the risk of ingrown toenails and foot injuries, which can be difficult to heal in individuals with diabetes.
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