A nurse is caring for a client who has anemia. Which of the following assessment findings should the nurse anticipate with the client's condition?
Bradycardia
Headache
Flushed skin color
Heat intolerance
The Correct Answer is B
Choice A reason:
Bradycardia is incorrect. Bradycardia refers to a slow heart rate, and while anaemia can lead to an increased heart rate (tachycardia) as the body tries to compensate for the decreased oxygen levels, it is not typically associated with bradycardia.
Choice B reason:
Headache Anaemia is a condition characterized by a decreased number of red blood cells or a decrease in the amount of haemoglobin in the blood, leading to reduced oxygen-carrying capacity. This can result in decreased oxygen delivery to various tissues and organs, including the brain. As a result, clients with anaemia often experience symptoms such as fatigue, weakness, and headaches.
Choice C reason:
Flushed skin colour - Anaemia is more likely to cause paleness of the skin (pallor) due to the decreased haemoglobin levels, rather than flushed skin colour.
Choice D reason:
Heat intolerance - Heat intolerance is not a typical symptom of anaemia. It might be seen in conditions affecting the thyroid or related to hormonal imbalances, but it is not directly related to anaemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
A calcium level of 11.5 mg/dL is elevated. Normal calcium levels typically range from 8.5 to 10.5 mg/dL. Hypercalcemia can lead to various complications, including cardiac arrhythmias and neurological symptoms. The nurse should notify the provider of this finding for further evaluation and management.Choice B reason
Serum albumin level 3.9 g/dL is not appropriate. This level is within a reasonable range for serum albumin. It might be an indicator of nutritional status, but it's not an urgent concern.
Choice C reason:
Output exceeding intake over a 12-hour period may indicate fluid imbalance or inadequate intake compared to output. However, without further context, such as the client's overall fluid status, this finding alone may not be alarming. The nurse should assess the client's hydration status, consider potential causes of increased output, and address any concerns accordingly. While the nurse may need to monitor closely and address any potential issues, immediate notification of the provider may not be necessary based solely on this finding.Choice D reason:
Fasting blood glucose level 105 mg/dL is not appropriate: A fasting blood glucose level of 105 mg/dL is slightly elevated, but it's not a critically high value. The nurse should monitor blood glucose levels and collaborate with the healthcare team to manage blood glucose appropriately.
However, if the client has a history of diabetes or if there are other concerning factors, such as consistent high glucose levels or symptoms of hyperglycemia, the nurse may need to monitor closely and notify the provider for further evaluation and management. Otherwise, this finding alone may not warrant immediate notification.Correct Answer is C
Explanation
Choice A Reason:
NG tube with suction apparatus should not be recommended. NG tubes and suction are not routine equipment for managing cystic fibrosis. They might be used for other medical conditions, such as digestive issues or nutritional support.
Choice B Reason:
Chest tube with a drainage system should not be recommended -. Chest tubes and drainage systems are used to manage conditions like pneumothorax or pleural effusion, which are not directly related to cystic fibrosis.
Choice C Reason:
A chest physiotherapy (CPT) vest, also known as a high-frequency chest wall oscillation (HFCWO) vest, is commonly used by clients with cystic fibrosis to help clear mucus from the lungs. The vest vibrates at high frequency, loosening the mucus and making it easier for the client to cough it up, thus helping to manage respiratory symptoms and reduce the risk of infections.
Choice D Reason:
A peak flow meter is typically used for clients with asthma to measure the maximum speed of exhalation, which helps in assessing asthma control. While it can be useful for monitoring lung function, it is not specific to cystic fibrosis, where the primary concern is airway clearance rather than peak flow measurement.
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