A nurse is caring for an 84-year-old male client in the medical unit.
The client was admitted from a provider’s office with complaints of fatigue, dizziness, and shortness of breath. The nurse reviews the client’s medical records to prepare the client’s plan of care.
The client demonstrates mild orthostatic hypotension, with a drop in blood pressure upon standing.
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 []
Based on the provided information, the client is most likely experiencing Anemia. Here’s how the diagram should be completed:
Condition
- Anemia
Actions to Take
- Administer prescribed medications
- Monitor vital signs regularly
Parameters to Monitor
- Hemoglobin levels
- Blood pressure
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The weights from the traction device should only be removed if the client develops a life- threatening situation. This is to ensure the client’s immediate safety and address the critical condition.
Choice B rationale
The client should not have the weights removed for repositioning in the bed. Proper techniques should be used to reposition the client without removing the weights to maintain the effectiveness of the traction.
Choice C rationale
Complaints of pain should be addressed by assessing the cause and providing appropriate pain management, but the weights should not be removed as it can compromise the traction.
Choice D rationale
The weights should not be removed for an x-ray. The traction can be maintained during imaging procedures to ensure continuous treatment.
Correct Answer is ["72"]
Explanation
Step 1 is to calculate the burned area using the Rule of Nines. The Rule of Nines assigns percentages to different body areas to estimate the total body surface area (TBSA) affected by burns. For example, each arm is 9%, each leg is 18%, the front and back of the torso are each 18%, and the head is 9%.
Step 1: Calculate the burned area. If the client has burns on the front and back of both legs, the calculation would be: (18% + 18%) + (18% + 18%) = 72%
The final calculated answer is 72%.
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