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
The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}
The client presents with classic signs of anemia, including fatigue, pallor, low hemoglobin, low hematocrit, and low ferritin levels, along with a vegan diet and use of NSAIDs (naproxen), which increase the risk of gastrointestinal bleeding. Orthostatic hypotension risk requires immediate safety education, while identifying potential occult bleeding is essential for determining the underlying cause of anemia before long-term management can be effective.
Rationale for correct choices:
• Instruct the client to rise slowly from a sitting position: Clients with iron deficiency anemia often experience orthostatic hypotension due to decreased oxygen-carrying capacity and reduced circulating red blood cell mass. Standing up too quickly can lead to dizziness, syncope, or falls because the body cannot adequately compensate for postural changes in blood pressure. Teaching slow position changes is a priority safety intervention to prevent injury.
• Evaluate a stool sample for occult blood: After ensuring safety, identifying the underlying cause of iron deficiency is essential. NSAID use (naproxen) increases the risk of gastrointestinal irritation and chronic bleeding, which may not be visibly apparent. A stool occult blood test helps detect hidden GI blood loss contributing to anemia. This step is critical for determining whether ongoing bleeding is the cause of the client’s low iron stores.
Rationale for incorrect choices:
• Perform a nutritional evaluation on the client: Although nutritional assessment is important in a vegan client, it is not the immediate priority in this scenario. The client already has laboratory-confirmed iron deficiency anemia with significantly low ferritin, suggesting a more urgent need to rule out active blood loss. Nutrition assessment is part of long-term management but does not address potential ongoing pathology causing anemia.
• Assist client in balancing activity with rest: Energy conservation strategies are appropriate for anemia-related fatigue; however, they do not address the underlying cause or immediate diagnostic priorities. While helpful for symptom management, this intervention does not prevent complications or identify potential bleeding sources.
• Administer prescribed iron supplementation: Iron supplementation is an important treatment but should not be the first priority before identifying the cause of anemia. Giving iron without evaluating for possible gastrointestinal bleeding could delay diagnosis of a potentially serious condition such as NSAID-induced GI hemorrhage. Priority must be given to safety and investigation of underlying etiology.
• Administer antibiotics: There is no evidence in the assessment findings that this client has an active infection requiring antibiotic therapy. The client’s white blood cell count is within normal range, and there are no signs such as fever, localized infection, or inflammatory symptoms suggestive of a bacterial process. The clinical picture is consistent with iron deficiency anemia rather than infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["D","E","G"]
Explanation
Assessment of a client with anemia focuses on identifying manifestations of decreased oxygen-carrying capacity and possible hemodynamic instability. Iron deficiency anemia commonly presents with fatigue, weakness, pallor, tachycardia, hypotension, and reduced tolerance to activity due to inadequate hemoglobin levels. Laboratory findings such as low hematocrit and hemoglobin confirm the diagnosis, while functional limitations help determine severity. Follow-up is needed for findings that reflect impaired perfusion, decreased oxygen delivery, or worsening clinical status.
A. Oxygen saturation of 97% on room air is within the expected range and does not require immediate follow-up. Although the client is anemic, pulse oximetry measures oxygen saturation of hemoglobin present, not the total hemoglobin available for oxygen transport. This finding is stable.
B. A pain level of 0/10 does not require follow-up because the client denies pain or discomfort. Pain is not a presenting issue in this case, and there is no indication of acute distress requiring intervention. Therefore, this finding is expected and nonconcerning.
C. Temperature of 36.8°C (98.2°F) is within the normal range and does not indicate infection or another acute problem. Since there are no signs of fever or systemic inflammatory response, this finding does not require additional follow-up.
D. Hematocrit of 24% is significantly below the normal range and indicates substantial anemia. This finding reflects reduced red blood cell volume and impaired oxygen delivery to tissues, contributing to fatigue, weakness, and shortness of breath. It requires follow-up and treatment monitoring.
E. Blood pressure of 98/64 mm Hg is lower than expected and may indicate decreased tissue perfusion, especially when combined with tachycardia and fatigue. In the setting of anemia, hypotension can worsen symptoms of weakness and dizziness. This finding should be monitored closely and followed up.
F. Bilateral breath sounds that are clear and present throughout are normal findings and do not require follow-up. There is no indication of respiratory compromise such as crackles, wheezing, or diminished breath sounds. This assessment is reassuring rather than concerning.
G. Activity level: Difficulty keeping up with grandchildren and shortness of breath after climbing stairs indicate reduced activity tolerance, which is a significant manifestation of anemia. This reflects decreased oxygen delivery to muscles and tissues during exertion. Reduced functional capacity requires follow-up to evaluate severity and response to treatment.
Correct Answer is D
Explanation
After application of an external fixator for a tibial fracture, neurovascular assessment is a priority to detect complications such as compartment syndrome, impaired circulation, or nerve compression. The nurse must frequently assess circulation, sensation, movement, pain, and skin temperature of the affected extremity. Early identification of compromised blood flow helps prevent permanent tissue damage. Postoperative care also focuses on preventing infection and maintaining proper device stability.
A. Maintaining the affected extremity in a dependent position is incorrect because the extremity is usually elevated above heart level to reduce swelling and promote venous return. A dependent position can increase edema, pain, and pressure within the tissues, which may worsen circulation and increase the risk of compartment syndrome.
B. Adjusting the clamps on the fixator frame is not a nursing responsibility and should only be done by the orthopedic provider. Manipulating the frame can disrupt bone alignment, compromise healing, and increase the risk of injury. The nurse should monitor the device but not alter its structure.
C. Wrapping sterile gauze on the sharp point of the pins is not appropriate because the pin ends should remain visible for inspection and should not be covered unnecessarily unless specifically ordered. Routine pin site care focuses on preventing infection around the insertion site rather than covering the external hardware tips.
D. Palpating the dorsalis pedis pulse is the correct action because it helps assess distal circulation and detect early signs of vascular compromise after surgery. Reduced or absent pulses may indicate swelling, compartment syndrome, or impaired arterial blood flow. Frequent neurovascular checks are essential in the immediate postoperative period following tibial fracture fixation.
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