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 C
Explanation
A. Chest tube with a drainage system: A chest tube is typically used for pneumothorax or pleural effusion, not as a routine treatment for cystic fibrosis. While some clients with severe lung disease may require one in emergencies, it is not standard home care equipment.
B. NG tube with suction apparatus: While some clients with cystic fibrosis may require enteral feeding for nutritional support, an NG tube with suction is not a standard home intervention. Suctioning is generally needed for acute gastrointestinal obstruction rather than routine CF management.
C. Chest physiotherapy vest: This device helps loosen and mobilize thick mucus from the airways, improving airway clearance and reducing the risk of infections. It is a critical component of daily CF management and is commonly used in home settings.
D. Peak flow meter: A peak flow meter is more commonly used in asthma to monitor airway obstruction. In CF, lung function is better assessed with spirometry rather than peak expiratory flow, making this device less useful for routine home monitoring.
Correct Answer is B
Explanation
A. "This device delivers heat via electrodes that are attached to the affected area.": A TENS unit does not use heat for pain relief. It works by delivering low-voltage electrical impulses to the skin, stimulating nerve fibers to reduce pain perception.
B. "Adjust the dial until you feel a pins-and-needles sensation.": The intensity of the electrical stimulation should be adjusted to a comfortable level where the client feels a tingling or pins-and-needles sensation. This indicates that the nerves are being stimulated appropriately for pain relief.
C. "You can apply the electrodes directly over sensitive areas of skin.": Electrodes should not be placed on irritated, broken, or sensitive skin, as this can cause discomfort or skin damage. Placement should follow guidelines to ensure effective and safe pain management.
D. "This device requires access to a 220-volt outlet.": TENS units are battery-operated and do not require a high-voltage power source. This makes them portable and convenient for home use.
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