The nurse is caring for the client who has iron deficiency anemia.

Exhibits

Which of the following instructions should the nurse include? Select all that apply.

Take the medication on an empty stomach.

Increase sources of fiber in the diet.

Take the medication with a source of vitamin C.

Take an antacid within 30 min after medication administration.

Increase intake of milk and dairy products.

Answer and Explanation

Correct Answer : A,B,C

A. Take the medication on an empty stomach: Iron is best absorbed in an acidic environment, so taking it 1 hour before or 2 hours after meals optimizes absorption. Although some clients may experience GI upset, the empty stomach approach remains ideal for absorption.
B. Increase sources of fiber in the diet: Iron supplements commonly cause constipation. Increasing dietary fiber through fruits, vegetables, and whole grains helps counteract this effect and promotes regular bowel function.
C. Take the medication with a source of vitamin C: Vitamin C enhances iron absorption by converting it into its more absorbable ferrous form. Pairing the supplement with orange juice or other vitamin C-rich foods improves treatment effectiveness.
D. Take an antacid within 30 min after medication administration: Antacids increase gastric pH, which reduces iron solubility and absorption. They should be avoided within 2 hours before or after iron intake to maintain optimal efficacy of the supplement.
E. Increase intake of milk and dairy products: Dairy products are rich in calcium, which competes with iron for absorption in the small intestine. Consuming them close to iron administration diminishes the supplement’s effectiveness and should be avoided.

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Correct Answer is D

Explanation

A. Position the head of bed greater than 45°: Elevating the head of the bed to about 30 degrees is recommended to promote venous drainage and reduce intracranial pressure (ICP). Raising it beyond 45 degrees can decrease cerebral perfusion pressure and potentially worsen the condition.
B. Apply heating blanket as needed: Applying a heating blanket can increase metabolic rate and body temperature, which may increase cerebral metabolism and ICP. Cooling measures are typically preferred to prevent fever in clients with increased ICP.
C. Administer laxatives rectally: While avoiding constipation and straining during bowel movements is important to prevent increased ICP, rectal administration of laxatives can stimulate vagal responses, potentially causing bradycardia or increased ICP. Oral laxatives are generally preferred.
D. Decrease stimulation in environment: Reducing environmental stimuli such as noise, bright lights, and unnecessary interactions helps prevent sudden increases in ICP by minimizing client agitation and metabolic demand; which is a crucial intervention in managing increased ICP.

A. Irritability and anxiety B. Sinus rhythm with peaked T waves C. Shallow respirations D. Hypoactive bowel sounds

Correct Answer is B

Explanation

A. Irritability and anxiety: These symptoms are more commonly associated with hypokalemia or other electrolyte imbalances but are nonspecific for hyperkalemia. They do not reliably indicate elevated potassium levels.
B. Sinus rhythm with peaked T waves: Peaked T waves on the ECG are a classic early sign of hyperkalemia, reflecting altered cardiac repolarization due to elevated serum potassium. This finding requires prompt recognition to prevent life-threatening arrhythmias.
C. Shallow respirations: Respiratory muscle weakness can occur in severe hyperkalemia but is a late and less specific sign. Shallow respirations often indicate respiratory distress and require urgent assessment but are not the earliest indicators of hyperkalemia.
D. Hypoactive bowel sounds: Decreased bowel motility is more typical in hypokalemia and is less common in hyperkalemia. While electrolyte imbalances affect the GI tract, hypoactive bowel sounds alone do not strongly indicate hyperkalemia.

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The nurse is caring for the client who has iron deficiency anemia. Exhibits Which of the following instructions should the nurse include? Select all that apply.

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The nurse is caring for the client who has iron deficiency anemia.

Exhibits

Which of the following instructions should the nurse include? Select all that apply.