A client is admitted for observation with reports of progressively increasing fatigue over the past month and a brief episode of dizziness that occurred today. The client has a history of heartburn and indigestion that is self-treated with ibuprofen and antacids. Which assessment finding should the nurse report immediately to the healthcare provider?

Reference Range:

Guaiac stool [negative]

Hemoglobin (14 to 18 g/dl. (140 to 180 g/L)]

Hematocrit [42% to 52% (0.42 to 0.52 volume fraction)]

Gastric Acid pH (1.5 to 3.5)

Positive guaiac of stool.

Hematocrit 42% (0.42 volume fraction).

Gastric pH 2.0.

Hemoglobin 13 g/dL (130 g/L).

Answer and Explanation

The Correct Answer is A

A) Positive guaiac of stool:
A positive guaiac test indicates the presence of occult (hidden) blood in the stool, which may suggest gastrointestinal bleeding. Given the client’s history of heartburn, indigestion, and self-treatment with ibuprofen and antacids, gastrointestinal irritation or ulceration may be occurring, leading to bleeding. Gastrointestinal bleeding can cause fatigue, dizziness, and other symptoms. Therefore, it is essential to report this finding immediately to the healthcare provider for further evaluation and management.

B) Hematocrit 42% (0.42 volume fraction):
A hematocrit level within the reference range (42% to 52%) is considered normal. While a slight decrease in hematocrit may indicate anemia, it is not an urgent finding that requires immediate reporting. The client’s hematocrit level of 42% is within the normal range, so it does not warrant immediate concern.

C) Gastric pH 2.0:
A gastric pH of 2.0 falls within the normal range (1.5 to 3.5) for gastric acid pH. This finding indicates normal gastric acidity and does not suggest an acute problem that requires immediate reporting to the healthcare provider.

D) Hemoglobin 13 g/dL (130 g/L):
A hemoglobin level of 13 g/dL is slightly below the lower end of the reference range (14 to 18 g/dL) but does not indicate a critical condition requiring immediate intervention. While it may suggest mild anemia, it is not an urgent finding that necessitates immediate reporting to the healthcare provider.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

Answer: D. Antiretroviral medication prevents the transmission of the virus.

Rationale:

A. The viral load can be decreased to an undetectable level:
This statement reflects an accurate understanding of antiretroviral therapy. Effective treatment can reduce the viral load to undetectable levels, which is a key goal of HIV treatment, allowing individuals to live healthier lives and reducing the risk of transmitting the virus to others.

B. HIV infection is not cured by the antiretroviral regimen:
This statement is also accurate. Antiretroviral therapy (ART) effectively manages HIV infection but does not cure it. Patients need to remain on medication for life to control the virus and maintain their health.

C. The medications can decrease acquired AIDS-related complications:
This statement is correct as well. Antiretroviral medications can help manage HIV and prevent the progression to AIDS, thereby reducing the likelihood of complications associated with AIDS, such as opportunistic infections.

D. Antiretroviral medication prevents the transmission of the virus:
This statement requires additional instruction because, while effective antiretroviral therapy can significantly reduce the risk of transmission, it does not entirely prevent it. Patients with an undetectable viral load have a greatly reduced risk of transmitting HIV to sexual partners (often summarized as "U=U" or "Undetectable = Untransmittable"), but it is crucial to understand that there is still a small risk involved. Therefore, additional education is necessary to clarify the need for continued safe practices, such as using condoms, even when on effective therapy.

A. Apply the lotion to plaques on the face. B. Rub the lotion into the area twice daily for 5 weeks. C. Use gloves to rub the lotion into the area. D. Massage the lotion into the psoriasis plaques.

Correct Answer is D

Explanation

A) Apply the lotion to plaques on the face: Betamethasone valerate lotion is a potent corticosteroid that is generally not recommended for use on the face due to the risk of adverse effects, such as skin thinning and irritation. Therefore, applying the lotion to plaques on the face is not advisable.
B) Rub the lotion into the area twice daily for 5 weeks: While it is essential to follow the prescribed frequency and duration of medication use, specific instructions for betamethasone valerate lotion may vary depending on the severity of the condition and the healthcare provider's recommendations. This instruction lacks specificity and may not be accurate for all clients.
C) Use gloves to rub the lotion into the area: While wearing gloves may be necessary when applying certain topical medications to prevent contact dermatitis or to protect the hands, it is not typically required when using betamethasone valerate lotion. This instruction may be unnecessary and could lead to unnecessary waste of gloves.
D) Massage the lotion into the psoriasis plaques: This instruction is appropriate because it ensures proper absorption of the medication into the affected skin. Massaging the lotion gently into the psoriasis plaques helps enhance its penetration and effectiveness in treating the condition.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is teaching a client who has been diagnosed with HIV about the antiretroviral medication regimen. Which statement provided by the client requires additional instruction by the nurse?

Correct Answer is D

Explanation

Rationale:

A client with plaque psoriasis receives a new prescription for betamethasone valerate lotion. Which instruction should the nurse include in client teaching?

Correct Answer is D

Explanation

The nurse is planning the home care of a client who is receiving a mydriatic medication. Which environment is best for this client?

The nurse is caring for a client who takes methotrexate for rheumatoid arthritis and receives a prescription for adalimumab. Which instructions should the nurse provide the client?

The nurse administers the initial dose of cefoxitin to a client whose medical record indicates an allergy to penicillin. Which finding is most important for the nurse to report to the healthcare provider?

A client who is newly diagnosed with diabetes insipidus is receiving a synthetic vasopressin intravenously. Which side effect of vasopressin reported by the client should the nurse report to the healthcare provider?

The nurse is administering the muscle relaxant baclofen by mouth (PO) to a client diagnosed with multiple sclerosis. Which intervention should the nurse implement?

A client with peptic ulcer disease receives a new prescription for cimetidine. Which statement provided by the client requires additional instruction by the nurse?