A nurse is admitting a client to a medical-surgical unit following a fall at home.

Exhibits

The nurse is discussing the client’s treatment plan with a provider. For each potential provider’s prescription, specify if the potential prescription is anticipated, nonessential, or contraindicated for the client.

Administer spironolactone

Administer an IV fluid bolus

Obtain an x-ray of the right hip

Administer an iron supplement

Obtain the client’s weight

Administer supplemental oxygen

Answer and Explanation

The Correct Answer is {"A":{"answers":"C"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"B"}}

Potential Prescription	Anticipated	Nonessential	Contraindicated
Administer spironolactone			✅
Administer an IV fluid bolus	✅
Obtain an x-ray of the right hip	✅
Administer an iron supplement		✅
Obtain the client’s weight	✅
Administer supplemental oxygen		✅

Choice A: Administer spironolactone

Spironolactone is a potassium-sparing diuretic used to manage heart failure and hypertension. However, the client’s potassium level is elevated at 5.3 mEq/L (normal range: 3.5 to 5 mEq/L) . Administering spironolactone could exacerbate hyperkalemia, leading to dangerous cardiac arrhythmias. Additionally, the client’s low blood pressure (89/60 mm Hg) and dehydration (indicated by dry skin and tenting) make the use of a diuretic inappropriate as it could further lower blood pressure and worsen dehydration .

Choice B: Administer an IV fluid bolus

The client presents with signs of dehydration (dry skin, tenting, low urine output) and hypotension (BP 89/60 mm Hg). An IV fluid bolus is anticipated to restore intravascular volume, improve blood pressure, and address

dehydration . This intervention is crucial to stabilize the client’s hemodynamic status and improve perfusion to vital organs .

Choice C: Obtain an x-ray of the right hip

The client reports pain in the right hip following a fall, which raises the suspicion of a fracture. An x-ray is essential to diagnose any potential fractures or dislocations, which are common in elderly patients after a fall 5.

Prompt imaging will guide appropriate management and prevent further complications .

Choice D: Administer an iron supplement

While the client has a history of iron-deficiency anemia and is on ferrous sulfate, the immediate need for iron supplementation is nonessential in the context of acute management of the fall and dehydration. The client’s hemoglobin (16 g/dL) and hematocrit (47%) are within normal ranges, indicating that anemia is currently well- managed . The focus should be on stabilizing the client’s acute condition.

Choice E: Obtain the client’s weight

Obtaining the client’s weight is anticipated as it is a critical parameter for calculating medication dosages, fluid requirements, and monitoring the client’s overall health status. Accurate weight measurement is particularly important in elderly patients with multiple comorbidities to ensure precise and safe medical management .

Choice F: Administer supplemental oxygen

The client’s oxygen saturation is 95% on room air, which is within the normal range (95-100%) . Therefore, administering supplemental oxygen is nonessential unless there is evidence of hypoxia or respiratory distress. The primary focus should be on addressing dehydration and hypotension.

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Correct Answer is D

Explanation

Choice A reason: Temperature 38.2°C (100°F)

A temperature of 38.2°C (100°F) is slightly elevated and could indicate an infection or other inflammatory response. However, it is not immediately life-threatening and does not require urgent intervention compared to other symptoms. Monitoring and further assessment are necessary, but it is not the highest priority.

Choice B reason: The client reports weakness of the lower extremities

Weakness of the lower extremities can be a side effect of epidural analgesia. While it is concerning and requires monitoring, it is not as immediately critical as severe hypotension. The nurse should assess the extent of the weakness and ensure the client’s safety, but it is not the top priority.

Choice C reason: The client reports some itching

Itching is a common side effect of opioid analgesia and, while uncomfortable, it is not dangerous. It can be managed with antihistamines or other medications. This symptom does not require urgent intervention and is not the highest priority.

Choice D reason: Blood pressure 80/56 mm Hg

A blood pressure of 80/56 mm Hg indicates significant hypotension, which can be life-threatening for both the mother and the fetus. Hypotension can lead to decreased perfusion to vital organs and the placenta, potentially causing fetal distress. Immediate intervention is required to stabilize the client’s blood pressure and ensure adequate blood flow to the fetus. This makes it the highest priority for the nurse to address.

A. Increasing age B. Cigarette smoking C. Family history of cardiac disease D. Diagnosis of diabetes mellitus

Correct Answer is B

Explanation

Choice A reason: Increasing age is a non-modifiable risk factor for cardiovascular disease. As people age, their risk of developing cardiovascular conditions naturally increases due to changes in the heart and blood vessels. However, age cannot be altered or controlled, making it a non-modifiable factor.

Choice B reason: Cigarette smoking is a significant modifiable risk factor for cardiovascular disease. Smoking damages the lining of the arteries, leading to atherosclerosis (narrowing and hardening of the arteries), which can result in heart attacks and strokes. Quitting smoking can significantly reduce the risk of cardiovascular disease, making it a key focus in prevention programs.

Choice C reason: Family history of cardiac disease is another non-modifiable risk factor. Genetics play a crucial role in the predisposition to cardiovascular diseases. If a close family member has had heart disease, the risk is higher. While this factor cannot be changed, awareness can lead to more proactive management of other modifiable risks.

Choice D reason: Diagnosis of diabetes mellitus is a complex risk factor. While having diabetes itself is not modifiable, the management of diabetes through lifestyle changes, medication, and monitoring can significantly reduce the risk of cardiovascular complications. Proper control of blood glucose levels, diet, and exercise are crucial in mitigating this risk.

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Choice B: Administer an IV fluid bolus

Choice C: Obtain an x-ray of the right hip

Choice D: Administer an iron supplement

Choice E: Obtain the client’s weight

Choice F: Administer supplemental oxygen

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