A nurse is assisting in the care of a client who is malnourished and states, ‘’I refuse to eat right now. It goes against my beliefs.’’ Which of the following responses should nurse make?

A) Ensuring that creases in the stockings on the front of the client's legs:
This action requires intervention. The stockings should be applied smoothly and without any wrinkles or creases, as these can cause pressure points that may lead to skin irritation, impaired circulation, or discomfort for the client. The nurse should ensure that the assistive personnel applies the stockings correctly and without any creases to prevent these issues.

B) Applying the stockings before the client gets out of bed:
This is an appropriate action. Antiembolic stockings should be applied while the client is in a resting position, preferably before getting out of bed, to prevent venous stasis and improve circulation. Applying them while the client is lying down allows for proper fitting and ensures the stockings are worn during periods of immobility.

C) Asking the client to point their toes before applying the stockings:
This is an acceptable action. Asking the client to point their toes helps to stretch and align the legs for proper stocking application, making it easier to apply the stockings without causing discomfort. It is a good practice to ensure the stockings are applied properly while the client's feet and legs are positioned correctly.

D) Turning the stockings inside out before applying them:
This is a correct action. Turning the stockings inside out can help to prevent the stockings from rolling or bunching during application. It also allows the assistive personnel to place them on the client more easily and ensures a proper fit. The stockings should be turned right-side out after being applied to the legs.

The nurse anticipates the client will likely require blood transfusion as evidenced by the client’s low hemoglobin and low hematocrit.

Rationale:

(i)

B. Blood transfusion: The client’s hemoglobin (9.1 g/dL) and hematocrit (27%) are significantly low, suggesting anemia due to gastrointestinal blood loss. A blood transfusion may be necessary to restore adequate oxygen-carrying capacity and prevent further hemodynamic instability.

(ii)

C. Low hemoglobin: A hemoglobin level below normal indicates blood loss, likely from a bleeding peptic ulcer. This finding supports the need for intervention to prevent further complications such as hypoxia or shock.

F. Low hematocrit: A low hematocrit confirms anemia and blood volume depletion. This finding, along with the client's symptoms and history of dark, tarry stools, further supports the need for a blood transfusion.

Incorrect:

(i)

A. Proton pump inhibitor therapy: While PPIs are essential for ulcer management, they do not immediately address acute blood loss

C. Antibiotic therapy: Antibiotics are needed to eradicate H. pylori, but they are not the primary intervention for anemia.

D. Surgical intervention: Surgery is considered only if bleeding is severe and refractory to medical management.

E. Intravenous fluid resuscitation: IV fluids can help stabilize blood pressure but do not directly correct anemia.

(ii)

A. Elevated white blood cell count: The client’s WBC count is normal, making it irrelevant to this scenario.

B. Positive H. pylori test: While H. pylori is the likely cause of the ulcer, this result does not directly indicate the need for a blood transfusion.

D. Epigastric tenderness: This is a symptom of peptic ulcer disease but does not directly relate to the need for a blood transfusion.

E. Dark, tarry stools: While indicative of gastrointestinal bleeding, the direct lab evidence of anemia (low hemoglobin and hematocrit) is more critical in determining the need for transfusion.