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 D
Explanation
Choice A rationale
Airway obstruction is not a common complication of a femoral head fracture or skin traction.
Choice B rationale
Pneumonia can cause shortness of breath but is not the most likely complication in this scenario.
Choice C rationale
Pneumothorax is less likely in this context compared to a fat embolism.
Choice D rationale
Fat embolism is a known complication of fractures, especially long bone fractures like the femoral head. It can cause respiratory distress and dyspnea.
Correct Answer is B
Explanation
Choice A rationale
Hypervolemia is not typically associated with extensive burn injuries. Burn patients often experience hypovolemia due to fluid loss from the burn wounds.
Choice B rationale
Hyperkalemia is a common finding in patients with extensive burn injuries. The destruction of cells releases potassium into the bloodstream, leading to elevated potassium levels.
Choice C rationale
Low hemoglobin is not a typical finding in the initial phase of burn injury. Hemoglobin levels may decrease later due to blood loss or hemodilution.
Choice D rationale
Metabolic alkalosis is not commonly associated with extensive burn injuries. Burn patients are more likely to experience metabolic acidosis due to tissue hypoxia and lactic acid accumulation.
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