The nurse is caring for a client who has been taking aspirin 81mg PO daily for the last six months. Which clinical findings are of most concern? (SELECT ALL THAT APPLY)
Temperature elevation of 100.4 ORGAN
Hemoglobin decrease from 128g/dl to 9.5g/dl
Serum potassium increase from 3.5 mEq/L 4.5 mEq/L
Gastrointestinal discomfort prior to eating breakfast
Several areas of ecchymosis on upper and lower extremities
Correct Answer : B,E
A. Temperature elevation of 100.4°F: While a slight fever can indicate infection or inflammation, it is not an immediate concern related to aspirin use. It requires monitoring but is not as critical as other findings.
B. Hemoglobin decrease from 128 g/dL to 5.5 g/dL: This significant drop in hemoglobin indicates severe anemia, which is a major concern and may suggest gastrointestinal bleeding, a known risk of long-term aspirin use.
C. Serum potassium increase from 3.5 mEq/L to 4.5 mEq/L: This level is still within the normal range and does not indicate a significant clinical issue. Normal potassium levels do not raise immediate concern.
D. Gastrointestinal discomfort prior to eating breakfast: While gastrointestinal discomfort can be a side effect of aspirin, it is not immediately alarming unless associated with more severe symptoms like bleeding or ulceration.
E. Several areas of ecchymosis on upper and lower extremities: This finding is concerning as it may indicate bleeding issues due to thrombocytopenia or increased bleeding tendency associated with aspirin therapy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Neutrophils 57%: This value reflects the percentage of neutrophils in the white blood cell count and does not specifically indicate the effectiveness of iron therapy. It is more related to the body’s immune response.
B. International Normalized Ratio (INR) 13 seconds: INR is a measure of blood coagulation and is not directly related to iron levels or the treatment of anemia. Therefore, this result does not indicate the success of ferrous sulfate therapy.
C. Total reticulocyte count 2.2% of total RBC count: An increased reticulocyte count indicates that the bone marrow is producing more red blood cells, which is a positive response to iron supplementation. A reticulocyte count around this percentage suggests an appropriate response to therapy for iron deficiency anemia.
D. Platelet count 250,000/µL: This is a normal platelet count and does not provide information specific to the effectiveness of iron therapy. It does not reflect the state of anemia or the response to iron supplementation.
Correct Answer is C
Explanation
A) Depending on the client's age, the findings may be normal: While changes in hair growth and nail texture can occur with aging, the specific combination of hair loss on the legs and thick toenails in a client with peripheral vascular disease is indicative of underlying circulatory issues rather than simply a normal aging process.
B) A blood clot may be forming and the client needs immediate intervention: While peripheral vascular disease does increase the risk of blood clots, the presence of no hair on the legs and thick toenails is more directly related to chronic insufficient blood flow rather than an acute clotting situation requiring immediate intervention.
C) Decreased oxygen to the tissues causes changes in hair growth and nail texture: This statement accurately describes the physiological changes occurring in peripheral vascular disease. Reduced blood flow and oxygen delivery to the lower extremities result in hair loss and thickened nails, as hair follicles and nail growth depend on adequate perfusion.
D) Decreased hair is most likely a hereditary condition and nail changes are related to fungus: While hereditary factors can influence hair loss and fungal infections can affect nails, in the context of peripheral vascular disease, the findings are primarily due to inadequate blood supply rather than hereditary issues or fungal infections.
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