A nurse in a provider's office is caring for a client.

Complete the following sentence by using the lists of options.

The first action the nurse should take is

followed by
_
.

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

The first action the nurse should take is assess for dizziness when standing followed by increase dietary iron intake.

Rationale:

Assess for dizziness when standing: The client’s orthostatic hypotension (BP drops from 132/60 to 102/50 mmHg upon standing) and tachycardia (HR 108/min) suggest possible symptomatic anemia. Evaluating for dizziness ensures client safety and helps determine the severity of anemia-related hypoxia.

Increase dietary iron intake: The client has iron deficiency anemia (low hemoglobin, hematocrit, RBC count, and ferritin). Since they follow a vegan diet, increasing plant-based iron sources (e.g., leafy greens, legumes, fortified cereals) and vitamin C intake can improve iron absorption.

Incorrect:

Administer IV fluids: While anemia can cause orthostatic hypotension, fluid resuscitation is not the first-line intervention unless dehydration is present.

Check for signs of bleeding: The client reports no pain or discomfort, and there is no evidence of active bleeding. Anemia is more likely due to chronic dietary deficiency rather than acute blood loss.

Administer vitamin B12 supplements: The client’s vitamin B12 level is slightly low but not critically deficient. The primary issue is iron deficiency, not pernicious anemia.

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Correct Answer is B

Explanation

A. Prepare the client for surgery: Surgical intervention is required to repair the evisceration, but the immediate priority is to protect the exposed organs from contamination and desiccation by covering them with a sterile saline-moistened dressing.

B. Cover the protrusion with a dressing soaked in 0.9% sodium chloride: This is the priority action to prevent the exposed organs from drying out and reduce the risk of infection. Sterile saline keeps the tissue moist, which is essential for preserving organ viability until surgical repair can be performed.

C. Obtain the client's vital signs every 5 min until the provider arrives: Monitoring vital signs is important to assess for shock, but it is not the first priority. Protecting the exposed abdominal contents takes precedence before initiating continuous monitoring.

D. Raise the head of the bed to 20°: The client should be placed in a low Fowler’s position with knees slightly flexed to reduce abdominal tension, but the most immediate action is to cover the exposed organs with a sterile saline-moistened dressing.

A. Instruct the client to report bleeding. B. Inform the client they might experience a low-grade fever. C. Check the client's gag reflex. D. Provide the client with sips of water.

Correct Answer is C

Explanation

A. Instruct the client to report bleeding: While important, assessing for bleeding is not the immediate priority. Minor blood-tinged sputum can be expected, but significant bleeding should be reported. Ensuring airway protection comes first.

B. Inform the client they might experience a low-grade fever: A mild fever may occur within the first 24 hours after bronchoscopy due to irritation, but addressing airway safety and aspiration risk takes precedence.

C. Check the client's gag reflex: The gag reflex must return before offering oral intake to prevent aspiration. The local anesthetic used for the procedure can suppress the reflex, increasing the risk of aspiration if the client drinks or eats too soon.

D. Provide the client with sips of water: Fluids should not be given until the gag reflex has returned. Providing water too soon could result in aspiration, leading to complications such as pneumonia.

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A nurse in a provider's office is caring for a client. Complete the following sentence by using the lists of options. The first action the nurse should take is ____ followed by _____ .

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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A nurse in a provider's office is caring for a client.

Complete the following sentence by using the lists of options.

The first action the nurse should take is

followed by
_
.