A nurse is caring for a client during a routine prenatal visit.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client’s progress.
The Correct Answer is []
In this scenario, the client is most likely experiencing iron deficiency anemia, based on the diagnostic results that show low hemoglobin (10 mg/dL), low hematocrit (31%), and low serum ferritin (9 mcg/L), which are below the normal ranges for a pregnant individual.
The correct answers are:
Potential Condition:
- a. Iron deficiency anemia
Actions to Take:
- a. Administer iron supplements (to address the anemia and increase iron levels)
- b. Teach the client about a diet rich in iron (to support iron supplementation and improve dietary intake of iron)
Parameters to Monitor:
- a. Hemoglobin levels (to assess improvements in oxygen-carrying capacity and monitor for anemia)
- b. Hematocrit levels (to monitor the volume of red blood cells and further assess anemia)
By addressing the low iron levels, administering supplements, and providing dietary guidance, the nurse can help correct the anemia. Monitoring hemoglobin and hematocrit will help track the client’s progress in overcoming the condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason:
Constipation is not typically associated with hyperthyroidism. Hyperthyroidism usually speeds up the body’s metabolism, leading to symptoms like increased bowel movements or diarrhea rather than constipation.
Choice B Reason:
Sensitivity to cold is more commonly associated with hypothyroidism, where the body’s metabolism slows down. In hyperthyroidism, patients often experience heat intolerance due to an increased metabolic rate.
Choice C Reason:
Weight gain of 4.5 kg (10 lbs) in 3 weeks is also more indicative of hypothyroidism. Hyperthyroidism generally causes weight loss despite an increased appetite because of the accelerated metabolism.
Choice D Reason:
Frequent mood changes are a common symptom of hyperthyroidism. The excess thyroid hormones can affect the nervous system, leading to symptoms such as anxiety, irritability, and mood swings.
Correct Answer is []
Explanation
The correct answers are:
Condition:
- a. Pneumothorax
(After a thoracotomy and chest tube insertion, pneumothorax is a potential complication as air can accumulate in the pleural space, compromising lung expansion.)
Actions:
- b. Administer oxygen as prescribed.
(To ensure adequate oxygenation while resolving the pneumothorax) - b. Ensure the chest tube is functioning properly.
(Ensuring the chest tube is removing air from the pleural space to restore lung expansion)
Parameters to Monitor:
- c. Respiratory rate and effort.
(To assess the client's respiratory status and detect any changes indicating distress or worsening pneumothorax) - c. Oxygen saturation levels.
(To continuously assess oxygenation and detect any hypoxia)
Rationale:
A pneumothorax is more likely post-thoracotomy, especially with a chest tube insertion, as air is a primary concern in the pleural space. Monitoring respiratory parameters like oxygen saturation and respiratory effort helps evaluate the client's respiratory function and chest tube efficacy.
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