A nurse is caring for an 84-year-old male client in the medical unit.

The client was admitted from a provider’s office with complaints of fatigue, dizziness, and shortness of breath. The nurse reviews the client’s medical records to prepare the client’s plan of care.

Exhibits

The client demonstrates mild orthostatic hypotension, with a drop in blood pressure upon standing.

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client’s progress.

Answer and Explanation

The Correct Answer is []

Based on the provided information, the client is most likely experiencing Anemia. Here’s how the diagram should be completed:
Condition

Anemia

Actions to Take

Administer prescribed medications
Monitor vital signs regularly

Parameters to Monitor

Hemoglobin levels
Blood pressure

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Free Nursing Study Resources

Correct Answer is []

Explanation

Based on the provided information, the client is most likely experiencing Anemia. Here’s how the diagram should be completed:
Condition

Anemia

Actions to Take

Administer prescribed medications
Monitor vital signs regularly

Parameters to Monitor

Hemoglobin levels
Blood pressure

A. Weak pedal pulses. B. Complaints of leg discomfort. C. Toes are warm and demonstrate a brisk capillary refill. D. Drainage at the pin sites.

Correct Answer is A

Explanation

Choice A rationale

Weak pedal pulses indicate vascular compromise, which is a complication of Buck’s traction. This can be caused by pressure on the tissues of the leg.

Choice B rationale

Complaints of leg discomfort are expected due to the traction and do not indicate a complication.

Choice C rationale

Toes that are warm and demonstrate brisk capillary refill are normal findings and do not indicate a complication.

Choice D rationale

Drainage at the pin sites is more relevant to skeletal traction, not Buck’s traction.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is []

Explanation

The nurse, caring for a client with Buck’s traction, is monitoring the client for complications of the traction. Which assessment finding indicates a complication of this form of traction?

Correct Answer is A

Explanation

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