Exhibits

Complete the diagram by choosing from the choices below to specify which condition the client is most likely experiencing, two actions the nurse should take to address the condition, and two parameters the nurse should monitor to assess the client's progress.

Choice A reason: A complete blood count (CBC) is the most relevant laboratory value to review for a client with iron deficiency anemia who reports increased fatigue. The CBC will provide important information about the levels of red blood cells, hemoglobin, and hematocrit, which are directly affected by iron deficiency. Monitoring these values will help determine if the client’s anemia is worsening or if the iron supplements are not effectively improving the blood count.

Choice B reason: The platelet count is part of a CBC but is not directly related to the symptoms of fatigue in iron deficiency anemia. While platelet levels are important for assessing clotting function, they do not provide the necessary information about red blood cell levels or hemoglobin concentration that are central to diagnosing and managing anemia.

Choice C reason: Serum electrolytes are important to monitor for overall health and hydration status, but they are not specifically related to the client’s anemia or the symptom of fatigue. Electrolyte imbalances typically do not cause fatigue related to anemia, so this is not the primary laboratory value to review in this context.

Choice D reason: Liver enzymes are important for assessing liver function and potential liver damage, but they are not directly related to iron deficiency anemia or the symptom of fatigue. While it is important to monitor liver health, especially if the client is on medications that affect the liver, the complete blood count is more relevant to the symptoms described.

Choice A reason: Administering medications as prescribed is a critical intervention for this client experiencing an acute asthma exacerbation. The prescribed medications, including albuterol and ipratropium bromide via nebulizer, act to relieve bronchospasm and improve airflow. Albuterol, a beta-2 adrenergic agonist, works by relaxing smooth muscles in the airway, while ipratropium, an anticholinergic, reduces mucus production and further enhances bronchodilation. Prednisone, a corticosteroid, reduces airway inflammation and prevents progression of the attack. Administering these medications promptly addresses the underlying pathophysiology of the asthma attack, improves oxygenation, and reduces the risk of complications like hypoxemia or respiratory failure. This is an essential and time-sensitive step in the client’s care.

Choice B reason: Providing client teaching is essential to address both immediate and long-term care needs. Education should focus on the correct use of inhalers, the importance of monitoring expiration dates, and adherence to prescribed medications. The nurse should explain proper inhalation techniques, the role of maintenance medications in preventing exacerbations, and the importance of identifying and avoiding triggers such as outdoor allergens and exercise without premedication. Additionally, discussing early signs of asthma worsening and when to seek medical attention can empower the client to better manage their condition and prevent severe exacerbations in the future. This intervention ensures the client has the tools to reduce recurrence and improve quality of life.

Choice C reason: Notifying the healthcare provider of the client's need for intubation is unnecessary at this stage based on the assessment data. While the client is in respiratory distress, indicated by increased respiratory rate and low oxygen saturation, they remain alert and responsive, with expiratory wheezes present—a sign that air is moving through the lungs. Intubation is reserved for clients in severe respiratory failure who are unable to maintain oxygenation or ventilation despite aggressive interventions. Administering nebulized medications and corticosteroids should stabilize the client and resolve the acute symptoms, making this action premature and inappropriate.

Choice D reason: Placing the client in the Trendelenburg position is contraindicated in asthma management and respiratory distress. The Trendelenburg position involves lowering the head of the bed and elevating the feet, which could worsen breathing by increasing pressure on the diaphragm, reducing lung expansion, and exacerbating hypoxemia. The preferred position for clients in respiratory distress is a high Fowler’s position, which promotes optimal lung expansion and improves oxygenation. The Trendelenburg position is used for specific conditions like shock or hypotension but has no role in managing asthma exacerbations.

Choice E reason: Asking the client for a list of current medications is a vital step in obtaining an accurate medication history and identifying potential factors contributing to the asthma exacerbation. An expired rescue inhaler suggests possible gaps in medication adherence or management. Understanding the client’s current medications, including any maintenance inhalers or allergy treatments, helps the healthcare team adjust the treatment plan effectively. Additionally, this step ensures that new prescriptions do not conflict with existing medications, reducing the risk of adverse interactions. It also highlights any missed preventive measures, such as maintenance therapy with inhaled corticosteroids, which can significantly reduce the frequency and severity of asthma attacks.