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 A

Explanation

A. Obtain bottles of warm, sterile 0.9% sodium chloride solution: Evisceration requires immediate coverage of the exposed organs with sterile, saline-moistened dressings to prevent drying and infection. Using warm saline helps maintain tissue viability and minimizes damage.

B. Apply a firm pressure dressing across the client's abdomen: A firm pressure dressing is inappropriate, as it could cause further damage to the eviscerated organs and increase intra-abdominal pressure, leading to ischemia or perforation.

C. Attempt to reinsert the protruding viscera: Reinserting the eviscerated organs is contraindicated due to the high risk of contamination, trauma, and further complications. The nurse should instead protect the organs with moist dressings and prepare the client for emergency surgery.

D. Place the client in left lateral recumbent position: The client should be placed in a low Fowler’s position with knees slightly flexed to reduce tension on the abdominal wound and prevent further protrusion of organs. A left lateral recumbent position does not provide the same benefit.

A. Increased body hair B. Decreased blood urea nitrogen level C. Hyperpigmentation of the skin D. Hypocalcemia

Correct Answer is C

Explanation

A. Increased body hair: Adrenal insufficiency leads to decreased androgen production, which may cause hair thinning rather than increased body hair. Hypertrichosis (excessive hair growth) is not a typical finding in adrenal insufficiency.

B. Decreased blood urea nitrogen level: Adrenal insufficiency is often associated with dehydration due to aldosterone deficiency, leading to reduced sodium retention and increased fluid loss. This can result in elevated blood urea nitrogen (BUN) levels rather than a decrease.

C. Hyperpigmentation of the skin: Increased melanocyte-stimulating hormone (MSH) activity, triggered by elevated adrenocorticotropic hormone (ACTH) levels, causes darkening of the skin, especially in sun-exposed areas, skin folds, and mucous membranes. This is a hallmark feature of primary adrenal insufficiency (Addison’s disease).

D. Hypocalcemia: Adrenal insufficiency is more commonly associated with hypercalcemia rather than hypocalcemia. Decreased cortisol levels can lead to reduced renal calcium excretion, contributing to elevated serum calcium levels.

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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 A

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
_
.