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 {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"},"F":{"answers":"A"}}
Explanation
Administer phytonadione (Vitamin K): Contraindicated
There is no indication that the client has a bleeding disorder or is on anticoagulant therapy requiring Vitamin K. This intervention is not relevant to the client's condition.
Apply cool compress to the extremity: Anticipated
A cool compress helps reduce pain and swelling associated with IV infiltration by constricting blood vessels and limiting the spread of IV fluid into surrounding tissues.
Elevate extremity: Anticipated
Elevation promotes venous return and reduces edema in the infiltrated extremity, aiding in symptom relief and tissue recovery.
Suggest irrigating the IV catheter: Contraindicated
Flushing or irrigating an infiltrated IV catheter could worsen tissue damage by forcing more fluid into the surrounding area. The catheter should be removed immediately.
Assist in inserting a new IV catheter in a site distal to the infiltration site: Contraindicated
A new IV should be placed proximal (above) rather than distal to the infiltration site to ensure proper circulation and avoid further infiltration.
Send the catheter tip for culture: Anticipated
Given the client’s edema, pain, and potential IV infiltration, infection is a concern. Sending the catheter tip for culture helps rule out phlebitis or IV-related infection.
Correct Answer is D
Explanation
A) "My husband won't need medication for breakthrough pain while using music therapy."
This statement is incorrect. While music therapy can help reduce pain perception and provide comfort, it is not a replacement for medications, especially for breakthrough pain. Breakthrough pain may still occur, and medications are often needed to manage it. Music therapy can complement the use of pain medications, but it does not eliminate the need for them.
B) "Playing music will increase my husband's alertness."
This statement is not accurate. Music therapy may enhance relaxation, reduce anxiety, and help manage pain, but it is not generally used to increase alertness in terminally ill patients. In fact, some music therapy techniques may be calming and soothing, which could encourage rest rather than increasing alertness.
C) "I will discontinue music therapy when my husband is no longer responsive."
This statement is incorrect. Music therapy can still be beneficial even if the client becomes less responsive. In hospice care, music therapy is often used to provide comfort, promote relaxation, and offer emotional support, even for clients who are less alert or responsive. Discontinuing therapy may deprive the client of a source of comfort.
D) "Music will distract my husband's awareness of the pain."
This statement is correct. Music therapy can serve as a distraction and help reduce the client's perception of pain by focusing their attention away from discomfort. It can promote relaxation, reduce anxiety, and alter the client's awareness of their pain, making it an effective complementary treatment for pain management in hospice care.
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