A nurse is caring for a patient who, upon awakening, was disoriented to person, place, and time. The client reports chills and chest pain that is worse upon inspiration. Which of the following actions is the nursing PRIORITY?

Obtain a sputum culture

Obtain baseline vital signs and oxygen saturation

Obtain a complete history from the client

Provide the PCV vaccine

Answer and Explanation

The Correct Answer is B

A.   While obtaining a sputum culture is important for diagnosing a potential respiratory infection, it is not the immediate priority. The patient’s vital signs and oxygenation status need to be assessed first to ensure safety and to inform clinical decisions.
B.   Assessing the patient’s vital signs and oxygen saturation is critical in this situation. The symptoms of disorientation, chills, and chest pain could indicate a serious condition such as pneumonia or pulmonary embolism.
C.   Gathering a complete history is valuable for understanding the patient's condition and underlying causes of symptoms. However, this action should follow immediate assessments of vital signs and oxygen saturation, especially in a potentially unstable patient.
D.   Administering the pneumococcal vaccine is important for prevention but is not an urgent action in this acute situation. The patient’s current symptoms require immediate assessment and intervention rather than preventive measures.

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Correct Answer is C

Explanation

A. Chronic blood loss is one of the most common causes of iron deficiency anemia. Conditions such as gastrointestinal bleeding (e.g., from ulcers, polyps, or cancer), heavy menstrual periods, or chronic blood donation can lead to a gradual loss of iron, resulting in anemia.
B. While liver problems can lead to various blood disorders, they are not a direct cause of iron deficiency anemia. Liver disease can affect iron metabolism and storage but does not typically cause iron deficiency unless accompanied by chronic blood loss or malnutrition.
C. Decreased folic acid absorption leads to folate deficiency anemia, not iron deficiency anemia. While folate is important for red blood cell production, it does not directly influence iron levels. This option is not a common cause of iron deficiency anemia.
D. Low dietary intake of iron is a well-known cause of iron deficiency anemia. Diets lacking in iron-rich foods (such as red meat, beans, and fortified cereals) can lead to insufficient iron stores and subsequent anemia.

A. Hematochezia B. Hypertension C. Tarry stool D. Coffee-ground emesis E. Hematemesis

Correct Answer is ["A","C","D","E"]

Explanation

A. This term refers to the passage of fresh blood through the anus, usually indicating lower GI bleeding (such as from the colon or rectum). It is a common and significant sign of GI bleeding.
B. Hypertension (high blood pressure) is generally not a sign of GI bleeding. In fact, GI bleeding typically leads to hypotension (low blood pressure) due to volume loss, making this choice incorrect.
C. Tarry stool (melena) indicates the presence of digested blood in the stool, typically resulting from upper GI bleeding. It appears black and sticky and is a common sign of GI bleeding.
D. This refers to vomiting that looks like coffee grounds, which indicates that blood has been present in the stomach and has undergone digestion. This is a classic sign of upper GI bleeding and is a significant symptom.
E. Hematemesis is the vomiting of blood, which can be bright red or resemble coffee grounds, depending on the source and severity of the bleeding. It is a common and serious sign of GI bleeding, particularly from the upper GI tract.

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A nurse is caring for a patient who, upon awakening, was disoriented to person, place, and time. The client reports chills and chest pain that is worse upon inspiration. Which of the following actions is the nursing PRIORITY?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

All of the following are common causes of Iron deficiency anemia, EXCEPT?

Correct Answer is C

Explanation

Which of the following are common signs or symptoms of GI bleeding? (Select all that apply)

Correct Answer is ["A","C","D","E"]

Explanation

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