The nurse is caring for a client who is taking diclofenac for rheumatoid arthritis. During a clinic visit, the client appears pale and reports increasing fatigue.
Which of the client’s serum laboratory values is most important for the nurse to review?
Total protein.
Hemoglobin.
Glucose.
Sodium.
The Correct Answer is B
Choice A rationale:
Total protein is a measure of the overall protein content in the blood. It includes albumin and globulin.
While it can be helpful in assessing nutritional status and liver function, it is not directly relevant to the client's current symptoms of pallor and fatigue.
Decreased total protein can indicate malnutrition or liver disease, but these conditions would not typically cause the specific symptoms of pallor and fatigue.
Therefore, total protein is not the most important laboratory value to review in this case.
Choice B rationale:
Hemoglobin is the protein in red blood cells that carries oxygen throughout the body.
Paleness (pallor) is a common sign of anemia, which is a condition characterized by a low hemoglobin level. Fatigue is also a common symptom of anemia, as the body's tissues are not receiving enough oxygen.
Diclofenac, a non-steroidal anti-inflammatory drug (NSAID), can cause gastrointestinal bleeding, which can lead to anemia. Therefore, it is essential for the nurse to review the client's hemoglobin level to assess for potential anemia.
Choice C rationale:
Glucose is a type of sugar that the body uses for energy.
Abnormal glucose levels can cause various symptoms, including fatigue. However, glucose levels would not typically cause pallor.
Additionally, there is no indication in the question stem that the client has any risk factors for diabetes or other disorders that affect glucose metabolism.
Therefore, glucose is not the most likely cause of the client's symptoms.
Choice D rationale:
Sodium is an electrolyte that helps regulate fluid balance in the body.
Abnormal sodium levels can cause various symptoms, including fatigue and weakness. However, sodium levels would not typically cause pallor.
Additionally, there is no indication in the question stem that the client has any risk factors for electrolyte imbalances. Therefore, sodium is not the most likely cause of the client's symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Chronic pain is a significant concern for this client, but it is not the immediate priority. Pain can be managed with medications and comfort measures, while aspiration can be life-threatening.
Tissue destruction by the tumor is likely contributing to the pain, but addressing the risk of aspiration takes precedence.
Uncontrolled pain can exacerbate anxiety and make it difficult to focus on other interventions, but ensuring airway safety is paramount.
Choice B rationale:
Anxiety and grieving are expected reactions to a diagnosis of esophageal cancer, and they should be addressed as part of the client's care plan. However, they are not the immediate priority in this case.
The progression of the disease is a significant stressor, but attending to the risk of aspiration is essential for the client's safety. Psychological distress can negatively impact coping and quality of life, but addressing physical needs takes precedence.
Choice D rationale:
Imbalanced nutrition is a concern for this client due to dysphagia and anorexia. However, it is not the immediate priority. Nutritional interventions can be implemented once the risk of aspiration is addressed.
Difficulty swallowing can lead to inadequate intake and malnutrition, but ensuring airway safety is the primary concern.
Anorexia can further contribute to nutritional deficits, but preventing aspiration is the most pressing issue.
Choice C is the priority nursing problem because:
The client's dysphagia puts them at immediate risk for aspiration, which can lead to pneumonia, respiratory failure, and even death.
Addressing the risk of aspiration is essential to ensure the client's safety and prevent life-threatening complications. It's crucial to implement interventions to minimize the risk of aspiration, such as:
Elevating the head of the bed during meals and for 30-60 minutes after eating Thickening liquids and pureeing foods
Encouraging small, frequent meals
Monitoring for signs of aspiration, such as coughing, choking, or difficulty breathing
Correct Answer is A
Explanation
Rationale for Choice A:
Pursed-lip breathing:
Creates back pressure in the airways, which helps to keep them open longer during exhalation.
Slows down the breathing rate, allowing for more complete exhalation and better emptying of the lungs. Prevents air trapping, which can worsen shortness of breath.
Promotes relaxation and reduces anxiety, which can also help to improve breathing.
Rationale for Choice B:
Side-lying position with knees bent:
May not be the most effective position for improving gas exchange in a client with emphysema. Could potentially restrict chest expansion and make breathing more difficult.
May not be comfortable for all clients.
Rationale for Choice C:
Increasing breathing rate:
Can lead to hyperventilation, which can worsen shortness of breath and anxiety. Can also cause fatigue and muscle exhaustion.
Rationale for Choice D:
Raising hands above the head:
Does not significantly expand the diaphragm or improve gas exchange. May actually make breathing more difficult for some clients.
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