A nurse is assisting with the care of a client who is admitted to the medical surgical unit.
Complete the following sentences by using the list of options:
The nurse anticipates the client will likely require
The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C","dropdown-group-3":"C"}
The nurse anticipates the client will likely require blood transfusion as evidenced by the client’s low hemoglobin and low hematocrit.
Rationale:
(i)
B. Blood transfusion: The client’s hemoglobin (9.1 g/dL) and hematocrit (27%) are significantly low, suggesting anemia due to gastrointestinal blood loss. A blood transfusion may be necessary to restore adequate oxygen-carrying capacity and prevent further hemodynamic instability.
(ii)
C. Low hemoglobin: A hemoglobin level below normal indicates blood loss, likely from a bleeding peptic ulcer. This finding supports the need for intervention to prevent further complications such as hypoxia or shock.
F. Low hematocrit: A low hematocrit confirms anemia and blood volume depletion. This finding, along with the client's symptoms and history of dark, tarry stools, further supports the need for a blood transfusion.
Incorrect:
(i)
A. Proton pump inhibitor therapy: While PPIs are essential for ulcer management, they do not immediately address acute blood loss
C. Antibiotic therapy: Antibiotics are needed to eradicate H. pylori, but they are not the primary intervention for anemia.
D. Surgical intervention: Surgery is considered only if bleeding is severe and refractory to medical management.
E. Intravenous fluid resuscitation: IV fluids can help stabilize blood pressure but do not directly correct anemia.
(ii)
A. Elevated white blood cell count: The client’s WBC count is normal, making it irrelevant to this scenario.
B. Positive H. pylori test: While H. pylori is the likely cause of the ulcer, this result does not directly indicate the need for a blood transfusion.
D. Epigastric tenderness: This is a symptom of peptic ulcer disease but does not directly relate to the need for a blood transfusion.
E. Dark, tarry stools: While indicative of gastrointestinal bleeding, the direct lab evidence of anemia (low hemoglobin and hematocrit) is more critical in determining the need for transfusion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) The client’s vital signs are checked every 8 hr: While vital signs are an important aspect of the client's health, this information is routine and doesn't provide new insights that would impact the overall plan of care during an interprofessional team meeting. It’s important to focus on changes in the client’s condition or specific concerns that require collaboration.
B) The client has developed difficulty ambulating: This is critical information to share during the interprofessional team meeting because it may require input from physical therapists, occupational therapists, or other specialists. Difficulty ambulating can indicate a need for reassessment of the client's mobility plan, and other team members need to be informed to develop appropriate interventions.
C) The client has state-sponsored health insurance: While the client’s insurance status is relevant for financial and discharge planning, it is not directly related to the clinical management or care coordination that would be discussed in an interprofessional team meeting. The focus should be on the client’s clinical condition and needs.
D) The client's next dressing change is scheduled in 4 hr: Although the dressing change is important for continuity of care, this is more of a task-related detail rather than critical clinical information that requires interprofessional discussion. The focus in a team meeting should be on the client's progress, challenges, and needs, not just routine care tasks.
Correct Answer is B
Explanation
A) Encourage the family to be with the child during mealtimes: While family support during mealtimes can be helpful, it is not the first priority in this situation. The most important step is to understand the child’s dietary habits and challenges in order to create a more targeted and effective approach to addressing the poor dietary intake.
B) Obtain the child’s dietary history: The first step should be to gather information about the child’s dietary history. Understanding what the child is eating, how often, and any potential barriers to proper nutrition (e.g., food preferences, allergies, or cultural practices) is crucial for identifying the root cause of the poor dietary intake. This information will guide the nurse in making appropriate recommendations for improving the child's nutrition.
C) Instruct the family to praise the child when they eat: While positive reinforcement can be a useful strategy, it is not the first step in addressing poor dietary intake. The nurse needs to assess the child’s dietary habits and any possible issues before recommending specific behavioral strategies.
D) Offer the child nutritious snacks between meals: Offering nutritious snacks is a good strategy for improving a child’s nutrition, but it should come after gathering a clear understanding of the child’s eating habits. Without knowing the child’s preferences and needs, it’s better to first assess and identify the cause of the poor intake before recommending snacks.
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