A nurse is reviewing the medical record of a client.
The client has a hemoglobin of 9.5 g/dL, platelets of 75,000 mcL, and a BUN of 22 mg/dL. The client reports increased fatigue and shortness of breath when ambulating, and weight has decreased by 10 lbs over the past month.
The abdomen is distended and tender to palpation with hypoactive bowel sounds.
Which of the following actions should the nurse take?
Initiate fluid restriction to manage abdominal distension.
Encourage the use of an incentive spirometer to improve lung function.
Increase monitoring of oxygen saturation levels.
Administer high-dose corticosteroids to reduce spinal inflammation.
The Correct Answer is C
Choice C rationale
The client presents with a hemoglobin level of 9.5 g/dL, which is below the normal range of 12 to 16 g/dL for females or 14 to 18 g/dL for males. This anemia reduces the oxygen-carrying capacity of the blood, explaining the reported shortness of breath and fatigue during ambulation. Increasing the monitoring of oxygen saturation is vital to ensure adequate tissue perfusion. The low platelet count of 75,000 mcL, below the normal 150,000 to 450,000 mcL, also necessitates careful assessment.
Choice A rationale
While the client has abdominal distension, initiating a fluid restriction is not indicated without a confirmed diagnosis of fluid volume excess or heart failure. The BUN of 22 mg/dL is slightly elevated above the normal range of 10 to 20 mg/dL, which could suggest mild dehydration or decreased renal perfusion rather than fluid overload. Restricting fluids could potentially worsen the client's hemodynamic status and exacerbate the tachycardia often associated with symptomatic anemia and decreased blood oxygenation.
Choice B rationale
An incentive spirometer is primarily used to prevent atelectasis and improve lung expansion in postoperative patients or those with restricted mobility. While the client reports shortness of breath, the underlying cause is likely hematological due to the hemoglobin of 9.5 g/dL rather than a primary restrictive or obstructive pulmonary issue. Using an incentive spirometer does not address the oxygen-carrying deficit caused by the anemia. The nurse must focus on interventions that monitor or improve systemic oxygen delivery.
Choice D rationale
Administering high-dose corticosteroids is an intervention typically reserved for acute inflammatory processes or spinal cord compression. There is no evidence in the medical record provided that suggests spinal inflammation is the cause of the client's symptoms. Corticosteroids carry significant side effects, including increased risk of infection and electrolyte imbalances. Given the low platelet count of 75,000 mcL and anemia, the nurse should focus on monitoring for bleeding and ensuring adequate oxygenation rather than unindicated steroid therapy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
Choice A rationale
This statement is incorrect because hot, dry skin is a hallmark characteristic of heat stroke rather than heat exhaustion. In heat stroke, the body's thermoregulatory mechanisms fail entirely, and the person stops sweating, leading to a dangerous rise in core body temperature, often exceeding 104 degrees Fahrenheit or 40 degrees Celsius. In contrast, patients experiencing heat exhaustion are typically still able to sweat profusely as their body attempts to dissipate heat through the process of evaporation.
Choice B rationale
Heat exhaustion often involves hypotension and tachycardia as the body attempts to compensate for significant fluid and electrolyte loss. Excessive sweating leads to a decrease in intravascular volume, which lowers blood pressure. The heart rate increases as a compensatory mechanism to maintain cardiac output and perfusion to vital organs. These clinical findings are essential for differentiating exhaustion from simpler heat cramps. Understanding these hemodynamics helps the nurse prioritize fluid resuscitation to prevent the progression to life-threatening heat stroke.
Choice C rationale
Altered mental status, confusion, seizures, or coma are definitive characteristics of heat stroke that distinguish it from heat exhaustion. As the core body temperature rises to critical levels, the central nervous system becomes impaired due to thermal injury and cerebral edema. While a person with heat exhaustion may feel weak or dizzy, they generally remain cognitively intact. The presence of neurological dysfunction signifies a medical emergency requiring immediate and aggressive cooling measures to prevent permanent brain damage or multi-organ failure.
Choice D rationale
Excessive sweating and clammy, pale skin are classic signs of heat exhaustion. During this stage, the thermoregulatory system is still functioning but is overwhelmed by the heat load and fluid depletion. The skin feels cool and moist because the body is still pushing blood to the periphery to encourage cooling through sweat. Normal lab parameters for sodium are 135 to 145 mEq/L, and these levels can fluctuate significantly during heat-related illnesses, requiring careful monitoring and replacement during treatment. .
Correct Answer is C
Explanation
Choice A rationale
Scheduling a CT scan is a diagnostic step used to identify adrenal adenomas or hyperplasia, which are common causes of primary hyperaldosteronism. However, in an acute presentation with a blood pressure of 220/135 mmHg, diagnostic imaging is not the immediate priority. The patient is experiencing a hypertensive crisis, which requires urgent physiological stabilization. While imaging is necessary for long-term treatment planning, the nurse must first address the life-threatening hemodynamic instability and electrolyte imbalances to prevent end-organ damage.
Choice B rationale
A low-sodium diet is a long-term management strategy for hyperaldosteronism to help control fluid retention and hypertension. However, in the presence of a hypertensive emergency, dietary modifications are insufficient and too slow to be effective. The patient requires immediate pharmacological intervention to lower blood pressure and prevent a cerebrovascular accident or myocardial infarction. Initial nursing actions must focus on acute interventions that produce rapid physiological changes rather than lifestyle or dietary adjustments that take days to manifest.
Choice C rationale
Monitoring for signs of fluid overload is the priority because aldosterone causes the kidneys to retain sodium and water while excreting potassium. Excess aldosterone leads to an expanded intravascular volume, contributing to the severe hypertension of 220/135 mmHg. The nurse must assess for peripheral edema, jugular venous distention, and pulmonary crackles. Managing volume status is critical to preventing heart failure and further escalation of the hypertensive crisis, making it the most vital assessment for a patient in this state.
Choice D rationale
Administering potassium supplements is necessary to correct the hypokalemia of 3.1 mEq/L, as the normal range is 3.5 to 5.0 mEq/L. However, potassium must be replaced with extreme caution in the setting of severe hypertension and potential renal impairment. While correcting the heart's electrical stability is important, the immediate threat to the patient's life is the extremely high blood pressure. Monitoring the systemic effects of the fluid and electrolyte imbalance takes precedence to guide safe administration of intravenous medications. .
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