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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

followed by .
Answer and Explanation

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.


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Related Questions

Correct Answer is C

Explanation

A. "Place an aspirin in your ostomy pouch to control odor.": Aspirin should never be placed in an ostomy pouch, as it can damage the pouch material and irritate the stoma. Deodorizers or dietary adjustments are safer alternatives for odor control.

B. "Your ostomy should start functioning in five days.": An ostomy typically begins functioning within 2 to 4 days postoperatively, depending on bowel motility. Waiting five days without output could indicate an obstruction or ileus, requiring medical evaluation.

C. "Empty your ostomy pouch when it becomes a third to halfway full.": Keeping the pouch from becoming too full prevents leaks, discomfort, and excessive pressure on the stoma. This practice helps maintain skin integrity and ostomy function.

D. "Notify your provider if your stoma becomes dark red.": A dark red stoma is normal and indicates good blood supply. However, a stoma that turns pale, dusky, or black requires immediate medical attention, as it suggests compromised circulation and possible necrosis.

Correct Answer is ["B","C","F"]

Explanation

  • How to check blood glucose at home: Since the client has a blood glucose level of 250 mg/dL, which is elevated, it is essential to teach the client how to monitor their blood glucose at home. Self-monitoring will help the client manage their diabetes effectively and recognize when to seek medical attention.
  • Check feet weekly on the same day each week: Given the presence of an open wound on the client's foot, it is important to emphasize proper foot care and regular inspection for any sores or changes. Checking feet weekly can help prevent complications such as infections or ulcers, especially in clients with diabetes.
  • Manifestations of hyperglycemia and hypoglycemia: Educating the client about the signs and symptoms of both hyperglycemia (e.g., increased thirst, frequent urination, fatigue) and hypoglycemia (e.g., shakiness, sweating, confusion) is crucial for safety. This knowledge empowers the client to take appropriate action when they experience these symptoms.
  • Instructions on how to take metoprolol: There is no indication in the provided information that the client is prescribed metoprolol. While teaching about medications is important, it should be based on the specific medications the client is taking.
  • Perform 100 min of physical activity per week: While physical activity is beneficial for overall health and can help manage diabetes, the emphasis should be on tailoring an exercise plan to the client's current health status and capabilities. A more individualized approach should be taken, and it may not be the priority at this stage due to the client's current condition.
  • Weight loss tips: While the client has reported recent weight loss, it is unclear whether this is intentional or a result of uncontrolled diabetes. Teaching weight loss tips may not be appropriate until the client’s diabetes is better managed and their nutritional needs are assessed more thoroughly.

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