The nurse is caring for a client who has been taking aspirin 81mg PO daily for the last six months. Which clinical findings are of most concern? (SELECT ALL THAT APPLY)

Temperature elevation of 100.4 ORGAN

Hemoglobin decrease from 128g/dl to 9.5g/dl

Serum potassium increase from 3.5 mEq/L 4.5 mEq/L

Gastrointestinal discomfort prior to eating breakfast

Several areas of ecchymosis on upper and lower extremities

Answer and Explanation

Correct Answer : B,E

A. Temperature elevation of 100.4°F: While a slight fever can indicate infection or inflammation, it is not an immediate concern related to aspirin use. It requires monitoring but is not as critical as other findings.

B. Hemoglobin decrease from 128 g/dL to 5.5 g/dL: This significant drop in hemoglobin indicates severe anemia, which is a major concern and may suggest gastrointestinal bleeding, a known risk of long-term aspirin use.

C. Serum potassium increase from 3.5 mEq/L to 4.5 mEq/L: This level is still within the normal range and does not indicate a significant clinical issue. Normal potassium levels do not raise immediate concern.

D. Gastrointestinal discomfort prior to eating breakfast: While gastrointestinal discomfort can be a side effect of aspirin, it is not immediately alarming unless associated with more severe symptoms like bleeding or ulceration.

E. Several areas of ecchymosis on upper and lower extremities: This finding is concerning as it may indicate bleeding issues due to thrombocytopenia or increased bleeding tendency associated with aspirin therapy.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

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

Explanation

A) Allow for rest periods between activities throughout the day: This intervention is essential for a client with activity intolerance. Incorporating rest periods helps to manage fatigue and allows for recovery, particularly when hypoxemia is a concern due to sickle cell anemia.
B) Provide supplemental oxygen when the pulse oximetry falls below 96%: Administering supplemental oxygen when oxygen saturation levels drop below 96% is crucial for preventing further hypoxemia and ensuring adequate tissue perfusion, thus addressing the client's activity intolerance.

C) Perform serial neurologic assessments to maintain safety and prevent injury: Regular neurologic assessments are vital, especially in clients with sickle cell anemia, who are at risk for complications like stroke. This intervention helps monitor for changes in neurological status, ensuring prompt action if needed.

D) Assess ability to perform activities of daily living (ADLs): Evaluating the client’s ability to perform ADLs provides valuable information on their functional status and helps tailor interventions to promote independence while considering their limitations due to hypoxemia.

E) Monitor blood pressure, pulse, and respirations after activity: This monitoring is important to evaluate the client’s response to activity and to detect any changes that could indicate distress or worsening hypoxemia. This information helps guide further interventions and ensures the client’s safety.

A. 2 inches 21 gauge B. 1 1/2 inch 27 gauge C. 5/8 inch 25 gauge D. 1/4 inch 19 gauge

Correct Answer is C

Explanation

A. 2 inches 21 gauge: This option is too long and too large in gauge for subcutaneous administration. Typically, a longer needle is not necessary for subcutaneous injections, especially for standard adult adipose tissue.

B. 1 1/2 inch 27 gauge: While this gauge is acceptable, the length is still longer than typically required for subcutaneous injections. A 1 1/2 inch needle is more suited for intramuscular injections.

C. 5/8 inch 25 gauge: This is the most appropriate choice for a subcutaneous injection. A 5/8 inch needle is typically adequate for subcutaneous tissue in adults, and a 25 gauge needle provides a suitable size for comfort while allowing the medication to be administered effectively.

D. 1/4 inch 19 gauge: This option is not suitable for subcutaneous injections. A 1/4 inch length is too short for effective penetration into subcutaneous tissue, and a 19 gauge needle is larger than necessary, which could increase discomfort.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse is caring for a client who has been taking aspirin 81mg PO daily for the last six months. Which clinical findings are of most concern? (SELECT ALL THAT APPLY)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The client problem of Activity Intolerance related to hypoxemia from sickling RBCs has been made for a client with sickle cell anemia. Which intervention should the nurse include in the plan of care? (SELECT ALL THAT APPLY)

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

Explanation

The nurse calculates that 0.74 mi of filgrastim must be administered to a client subcutaneously. The client weights 165 lbs. What length and gauge of needle is best to administer this medication?

Correct Answer is C

Explanation

The nurse is reviewing the chart of a client with a diagnosis of unstable angina. Which laboratory test(s) result(s) should the nurse recognize as an Indication of heart damage? (SELECT ALL THAT APPLY)

The nurse is teaching a client with hypertension about the prescribed bumetanide, a loop diuretic, 1 mg PO daily. Which statement, made by the client would indicate that the teaching has been effective?

A female client with iron-deficiency anemia is experiencing increased fatigue and a shiny red tongue. The nurse would anticipate seeing which additional assessment finding(s) (SELECT ALL THAT APPLY)

A client with borderline personality disorder reports to the nurse that they anxious & wants to cut their thigh. The nurse should first:

The nurse is administering Furosemide 40 mg PO to a client with peripheral edema. Which method should the nurse use to best evaluate the client's response to this medication?

The nurse is conducting dietary teaching for a client diagnosed with coronary artery disease. Which statement made by the client indicates an understanding of fat sources and the need to limit saturated fats?

Which statement, made by the client with coronary artery disease, alerts the nurse that the client may be experiencing difficulty adapting to the illness?

The nurse recognizes that which diagnostic test is used to detect the most common cause of chronic iron deficiency anemia?