A nurse is assisting with the care of a client who is admitted to the medical surgical unit.
Complete the following sentences by using the list of options:
The nurse anticipates the client will likely require
The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C","dropdown-group-3":"C"}
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) Report the healing status of the client's surgical site to the provider:
While this is an important aspect of the nurse’s responsibilities, it does not involve the client in decision-making. Reporting the healing status is a task that requires clinical assessment, but it doesn't allow the client to have a role in making decisions about their care or treatment options.
B) Assist the client to perform exercises and ambulate on the unit:
Assisting the client with exercises and ambulation is important for recovery, but it doesn’t directly involve the client in decision-making. The nurse is providing physical assistance, but this action is more about carrying out the care plan rather than consulting or involving the client in making decisions about their care.
C) Consult the client about options proposed by the physical therapist:
This option best involves the client in decision-making. It allows the nurse to discuss with the client the different options proposed by the physical therapist and gives the client the opportunity to make informed decisions about their own care. This approach supports patient autonomy and ensures the client is an active participant in their rehabilitation process.
D) Ask the client to rate their pain on a scale from 0 to 10 every 12 hr:
While assessing pain is important for managing the client’s comfort, it doesn’t necessarily involve the client in decision-making. The client is providing information, but the nurse is still the one determining the course of action regarding pain management based on that input. It is more about assessment than collaboration in decision-making.
Correct Answer is ["B","C","E"]
Explanation
A. Chronic health condition: The client has a history of Parkinson’s disease and anxiety, which are relevant but not immediate concerns. Chronic conditions require long-term management rather than urgent intervention.
B. Current level of consciousness: The client is restless and not following commands, which may indicate hypoxia, worsening infection, or sepsis. A change in mental status is a critical finding requiring immediate evaluation.
C. Oxygen saturation level: The oxygen saturation is 89% on room air, which is below the normal range (≥95%). This suggests respiratory compromise, likely due to pneumonia, requiring urgent oxygen support.
D. Heart rate: The client has a heart rate of 104/min, which is mildly elevated and expected due to fever and respiratory distress. However, it is not the most critical concern compared to respiratory distress and altered mental status.
E. Respiratory rate: The respiratory rate is 30/min, indicating tachypnea and increased work of breathing, suggesting respiratory distress or impending respiratory failure. This requires immediate intervention.
F. Tremors: Tremors are a common finding in Parkinson’s disease and do not require immediate intervention.
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