A nurse is caring for a group of clients on a medical unit. For which of the following clients should the nurse intervene immediately?

A client who had an appendectomy and has a urine output of 260 mL over 8 hr

A client who is immobile and has had an episode of urinary incontinence

A client who has COPD and an oxygen saturation of 99%

A client who has a concussion and has developed aphasia

Answer and Explanation

The Correct Answer is D

A. A client who had an appendectomy and has a urine output of 260 mL over 8 hr: A urine output of 260 mL over 8 hours is average (around 32.5 mL/hr), and it does not require immediate intervention. It is important to monitor, but there is no acute concern at this time.

B. A client who is immobile and has had an episode of urinary incontinence: While urinary incontinence can lead to skin breakdown and other issues, it is not immediately life-threatening. The nurse should address it with appropriate interventions, but it is not urgent.

C. A client who has COPD and an oxygen saturation of 99%: An oxygen saturation of 99% in a client with COPD is within normal limits. This indicates that the client’s respiratory status is stable and does not require immediate intervention.

D. A client who has a concussion and has developed aphasia: Aphasia after a concussion can indicate a serious complication, such as increased intracranial pressure or a brain injury. This requires immediate intervention to assess the severity of the condition and prevent further neurological damage.

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Free Nursing Study Resources

Correct Answer is ["B","C","E"]

Explanation

Rationale for Correct Choices:

Increase sources of fiber in the diet: Iron supplements, particularly ferrous sulfate, commonly cause constipation. Increasing dietary fiber through fruits, vegetables, and whole grains helps promote bowel regularity and prevent this common side effect.
Take the medication on an empty stomach: Iron is best absorbed in an acidic environment, and taking it on an empty stomach enhances its bioavailability. However, if gastrointestinal upset occurs, it may be taken with a small amount of food, but not with calcium-rich foods.
Take the medication with a source of vitamin C: Vitamin C (ascorbic acid) enhances the absorption of non-heme iron. Consuming iron with a vitamin C-rich beverage or food, like orange juice, increases iron uptake and supports effective treatment of iron deficiency anemia.

Rationale for Incorrect Choices:

Take an antacid within 30 min after medication administration: Antacids reduce stomach acidity, which impairs iron absorption. Iron requires an acidic environment to be absorbed effectively, so antacids should be avoided within 1–2 hours of iron administration.
Increase intake of milk and dairy products: Calcium in dairy products can bind to iron and inhibit its absorption. Iron should not be taken with milk or calcium-rich foods to ensure optimal effectiveness of the supplement.

A. Ensure the door to the client's room remains open. B. Wear sterile gloves during patient care. C. Wear a lead apron when providing client care. D. Place a dosimeter on the client's gown.

Correct Answer is C

Explanation

A. Ensure the door to the client's room remains open: The door should be kept closed to minimize exposure to radiation. Keeping the door open increases the risk of radiation exposure to others in the area.

B. Wear sterile gloves during patient care: Sterile gloves are not required for care during internal radiation therapy unless there is direct contact with bodily fluids or radioactive materials. Standard precautions are sufficient.

C. Wear a lead apron when providing client care: A lead apron is recommended for healthcare workers to protect themselves from radiation exposure during internal radiation therapy. The lead apron absorbs radiation and helps reduce the risk of harmful exposure.

D. Place a dosimeter on the client's gown: The dosimeter is typically worn by healthcare workers to measure radiation exposure, not the client. The client would not wear a dosimeter in this situation.

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A nurse is caring for a group of clients on a medical unit. For which of the following clients should the nurse intervene immediately?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for the client who has iron deficiency anemia. Exhibits Which of the following instructions should the nurse include? Select all that apply.

Correct Answer is ["B","C","E"]

Explanation

A nurse is caring for a client who is receiving a prescribed dose of internal radiation therapy. Which of the following actions should the nurse plan to perform?

Correct Answer is C

Explanation

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