The nurse cares for a client who is a pale and reports frequent fatigue, weakness and dizziness. Which serum laboratory test result is the nurse’s priority for planning care?

RBCs 4.3mEq/L

Potassium 4.8 mEq/L

Hemoglobin of 9g/dl

Sodium 137 mEq/L

Answer and Explanation

The Correct Answer is C

A) RBCs 4.3 million/µL:
While a low RBC count can indicate anemia, the specific value provided here is not suggestive of anemia, and it does not explain the patient's symptoms of fatigue, weakness, and dizziness as clearly as a low hemoglobin would.

B) Potassium 4.8 mEq/L:
This result is not concerning and does not directly relate to the patient's reported symptoms of pallor, fatigue, and dizziness. Therefore, this lab result does not take priority in planning care at this time.

C) Hemoglobin of 9 g/dl:
This result is consistent with anemia, which is a likely cause of the patient’s symptoms of fatigue, weakness, dizziness, and pallor. Anemia can lead to decreased oxygen delivery to tissues, explaining the symptoms the patient is experiencing. The priority action for the nurse should be to address the underlying cause of anemia and manage it to improve the patient’s oxygenation and overall condition.

D) Sodium 137 mEq/L:
Although sodium imbalances can cause neurological symptoms such as confusion or lethargy, the patient’s reported symptoms of pallor, fatigue, and dizziness are more likely related to anemia. Sodium is not the most urgent concern for this patient at the moment.

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Correct Answer is B

Explanation

A. Pernicious anemia:
Pernicious anemia is primarily caused by a deficiency in vitamin B12, often due to a lack of intrinsic factor needed for absorption in the gut. It typically presents with symptoms like weakness, fatigue, and neurological manifestations such as numbness or tingling. However, the client’s presentation does not suggest a vitamin B12 deficiency or neurological signs. Additionally, pernicious anemia is not typically associated with heavy menstrual periods,
which are more indicative of blood loss anemia.

B. Blood loss anemia:
Blood loss anemia is the most likely diagnosis in this case, especially in the context of heavy menstrual periods, which can cause significant blood loss over time. The client’s hemoglobin level of 6.9 g/dL indicates severe anemia, which is consistent with the cumulative effects of chronic blood loss. This type of anemia results from a decrease in red blood cell count due to bleeding, which can lead to symptoms like weakness, fatigue, and pallor.

C. Sickle cell anemia:
Sickle cell anemia is a genetic condition characterized by abnormally shaped red blood cells, which can lead to hemolysis and episodes of pain. While it can cause symptoms like fatigue and weakness, sickle cell anemia typically presents earlier in life and is more associated with episodes of severe pain and organ damage. Additionally, the patient’s history does not mention episodes of pain or other hallmark signs of sickle cell disease, such as swelling in the hands or feet or recurrent infections.

D. Aplastic anemia:
Aplastic anemia occurs when the bone marrow fails to produce enough blood cells, including red blood cells, white blood cells, and platelets. It presents with symptoms like weakness, fatigue, frequent infections, and bruising. Although this client does have anemia, the lack of additional signs (such as petechiae, infections, or bleeding) makes this diagnosis less likely. Aplastic anemia is also usually diagnosed with bone marrow biopsy, which is not suggested by this client's presentation.

A. Administer IV hydralazine and monitor blood pressure B. Administer oxygen at 10 liters/minute by non rebreather mask C. Administer acetaminophen 650 mg PO re-check temperature D. Infuse 0.9% sodium chioride at 120 mL/hour

Correct Answer is A

Explanation

A) "Administer IV hydralazine and monitor blood pressure":
. The patient's elevated blood pressure (172/92 mmHg), along with headaches and blurred vision, could indicate a hypertensive emergency, a serious condition where extremely high blood pressure can cause acute organ damage. Hydralazine is a common intravenous antihypertensive medication used to lower blood pressure quickly in these situations. The nurse should administer hydralazine as prescribed and closely monitor the blood pressure to prevent complications like stroke, heart failure, or kidney damage. Blood pressure management is the priority, as the patient's symptoms are likely related to the elevated BP.

B) "Administer oxygen at 10 liters/minute by non-rebreather mask":
. While oxygen therapy may be appropriate for patients with respiratory distress or hypoxia, the patient's SpO2 is 97% on room air, indicating that there is no immediate oxygenation issue. Administering oxygen unnecessarily could lead to oxygen toxicity, and it is not the priority in this case. The patient's main concern is their elevated blood pressure, which requires urgent management.

C) "Administer acetaminophen 650 mg PO re-check temperature":
. While headaches are one of the patient's complaints, there is no indication of fever (the temperature is 98.6°F). Administering acetaminophen would be appropriate for pain relief, but it is not the priority in this case. The elevated blood pressure and potential hypertensive emergency are the primary issues that need to be addressed first.

D) "Infuse 0.9% sodium chloride at 120 mL/hour":
. Normal saline (0.9% sodium chloride) is typically used for hydration, but there is no indication that the patient is dehydrated or that intravenous fluids are the priority. In cases of hypertensive emergency, the goal is to lower blood pressure using antihypertensive medications, not to infuse fluids. Fluid administration could potentially worsen the situation if the elevated blood pressure is not addressed first.

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The nurse cares for a client who is a pale and reports frequent fatigue, weakness and dizziness. Which serum laboratory test result is the nurse’s priority for planning care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a young female adult client who reports weakness, fatigue, and heavy menstrual periods. The client has a hemoglobin level of 6.9 g/dL. The nurse suspects which of the following types of anemia?

Correct Answer is B

Explanation

Correct Answer is A

Explanation

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