The nurse is caring for a client who is taking diclofenac for rheumatoid arthritis. During a clinic visit, the client appears pale and reports increasing fatigue.
Which of the client’s serum laboratory values is most important for the nurse to review?
Total protein.
Hemoglobin.
Glucose.
Sodium.
The Correct Answer is B
Choice A rationale:
Total protein is a measure of the overall protein content in the blood. It includes albumin and globulin.
While it can be helpful in assessing nutritional status and liver function, it is not directly relevant to the client's current symptoms of pallor and fatigue.
Decreased total protein can indicate malnutrition or liver disease, but these conditions would not typically cause the specific symptoms of pallor and fatigue.
Therefore, total protein is not the most important laboratory value to review in this case.
Choice B rationale:
Hemoglobin is the protein in red blood cells that carries oxygen throughout the body.
Paleness (pallor) is a common sign of anemia, which is a condition characterized by a low hemoglobin level. Fatigue is also a common symptom of anemia, as the body's tissues are not receiving enough oxygen.
Diclofenac, a non-steroidal anti-inflammatory drug (NSAID), can cause gastrointestinal bleeding, which can lead to anemia. Therefore, it is essential for the nurse to review the client's hemoglobin level to assess for potential anemia.
Choice C rationale:
Glucose is a type of sugar that the body uses for energy.
Abnormal glucose levels can cause various symptoms, including fatigue. However, glucose levels would not typically cause pallor.
Additionally, there is no indication in the question stem that the client has any risk factors for diabetes or other disorders that affect glucose metabolism.
Therefore, glucose is not the most likely cause of the client's symptoms.
Choice D rationale:
Sodium is an electrolyte that helps regulate fluid balance in the body.
Abnormal sodium levels can cause various symptoms, including fatigue and weakness. However, sodium levels would not typically cause pallor.
Additionally, there is no indication in the question stem that the client has any risk factors for electrolyte imbalances. Therefore, sodium is not the most likely cause of the client's symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
While teaching the client about infection prevention measures is important, it is not the most crucial action in this situation. The client is already exhibiting symptoms and has potentially been spreading the virus.
Focusing on isolation at this point is a more effective way to prevent further transmission.
Additionally, the client may be too ill to fully comprehend or adhere to instructions regarding masks, handwashing, and social distancing.
Choice B rationale:
Isolation is the most essential action to prevent the spread of COVID-19 to others. This is because:
COVID-19 is highly contagious and can spread through respiratory droplets produced when an infected person coughs, sneezes, or talks.
Isolation physically separates the infected person from others, reducing the risk of transmission.
Proper PPE, such as gloves, gowns, masks, and eye protection, creates a barrier between the healthcare worker and the infectious droplets, further minimizing the risk of spread.
Choice C rationale:
Reporting the COVID-19 result to the local health department is important for tracking and managing the spread of the virus. However, it is not as immediate a priority as isolating the client to prevent further transmission.
Choice D rationale:
Counseling family members about monitoring for symptoms is also important for early identification and containment of potential cases. However, it does not directly address the immediate risk of transmission from the actively symptomatic client.
Correct Answer is D
Explanation
Measuring oxygen saturation is not directly relevant to the administration of vancomycin or the monitoring of its potential side effects. While oxygen saturation is important to assess in patients with respiratory concerns, it does not provide information about kidney function, which is essential for safe vancomycin use.
Choice B rationale:
Auscultating bowel sounds, while a part of general abdominal assessment, is not the most crucial action before administering vancomycin. Vancomycin is not known to have significant effects on bowel motility, and its primary concern is nephrotoxicity.
Choice C rationale:
Assessing body temperature can be helpful in evaluating for infection, but it is not the most specific or sensitive indicator of vancomycin-related adverse effects. Fever can be a sign of various conditions, and it does not directly assess kidney function.
Choice D rationale:
Checking serum creatinine is the most essential action before administering vancomycin because it allows for assessment of kidney function. Vancomycin is primarily excreted by the kidneys, and impaired renal function can lead to elevated drug levels and increased risk of nephrotoxicity. By checking serum creatinine, the nurse can ensure that the patient's kidney function is adequate to safely excrete vancomycin and can adjust the dosage or frequency of administration if necessary.
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