A nurse is caring for a client who has sickle cell anemia. The client asks. "Why do I feel so tired and fatigued all of the time?" Which of the following information should the nurse provide?
"You have had a gastrointestinal bleed."
"You have a low ferritin level."
"You have an autoimmune disease."
"You have fewer red blood cells."
The Correct Answer is D
A. "You have had a gastrointestinal bleed.": While a GI bleed can cause anemia and fatigue, it is not a direct cause of fatigue in sickle cell anemia.
B. "You have a low ferritin level.": Low ferritin indicates iron deficiency anemia, not directly related to sickle cell anemia.
C. "You have an autoimmune disease.": Sickle cell anemia is a genetic disorder, not an autoimmune disease.
D. "You have fewer red blood cells." Sickle cell anemia results in a decreased number of healthy red blood cells (RBCs) because the sickled cells are fragile and prone to breaking apart. This leads to anemia, which reduces the blood's ability to carry oxygen, causing fatigue and tiredness.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Check the client's vital signs. While vital signs are important for overall assessment, the immediate priority when faced with wound dehiscence is to protect the wound and prevent further contamination or damage.
B. Cover the wound with a moist, sterile gauze dressing. The first priority is to cover the wound with a moist, sterile dressing to protect it from infection and to manage the drainage. This helps in creating a barrier to prevent contamination and supports the wound environment for healing.
C. Assess the client's pain level. Pain assessment is important but not the immediate priority in this case. Managing the wound and preventing further complications is more critical.
D. Obtain a culture and sensitivity of the wound drainage. While obtaining a culture is important to identify any infection, it is not the first action. Protecting the wound from further contamination comes first.
Correct Answer is A
Explanation
A. Heart rate: Adequate fluid resuscitation in burn patients helps to restore intravascular volume, improving circulation and perfusion. A decrease in heart rate indicates improved cardiac output and reduced compensatory tachycardia, suggesting adequate fluid replacement.
B. Weight: Fluid replacement can lead to an increase in weight due to the volume of fluids administered, not a decrease.
C. Urine output: Adequate fluid resuscitation typically increases urine output as renal perfusion improves.
D. Blood Pressure (BP): While BP can stabilize with adequate fluid resuscitation, it is not as direct an indicator as a decrease in heart rate in reflecting improved perfusion and hydration status.
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