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A nurse in a provider's office is assisting in the care of a client. Complete the following sentence: The first action the nurse should take is to reinforce education about...
- A. nutritional supplements followed by collecting data about nutritional intake.
- B. increasing fluid intake followed by monitoring respiratory rate.
- C. checking blood pressure followed by administering oxygen.
- D. assessing fatigue followed by ordering a chest X-ray.
Correct Answer: A
Rationale: The client's generalized weakness, fatigue, shortness of breath, and pale mucous membranes (Exhibit 1) with a vegan diet suggest anemia, likely iron deficiency. Reinforcing education about nutritional supplements (e.g., iron, Bâ‚â‚‚) addresses potential deficiencies vegans risk low iron and Bâ‚â‚‚ without fortified foods while collecting intake data identifies dietary gaps, guiding tailored therapy. Increasing fluids and monitoring respiration might help hydration or respiratory distress, but anemia is the primary issue, not fluid status. Checking blood pressure (132/60 to 102/50 mm Hg) shows orthostasis, a symptom, not the cause oxygen isn't indicated with 94% saturation. Assessing fatigue is ongoing, but a chest X-ray targets lungs, not anemia. Education and data collection tackle the root nutritional cause, aligning with holistic care and prevention, making it the nurse's first action.
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A nurse is caring for a client who has a new diagnosis of tuberculosis (TB). The client asks the nurse why she needs to take four different antituberculotic medications. Which of the following replies should the nurse make?
- A. The organism that causes TB becomes resistant to antituberculotic medications when you only take one medication.
- B. Taking several antituberculotic medications will protect your liver from toxic effects.
- C. People who have a severe form of TB need several antituberculotic medications, but those who have less severe TB need just one medication.
- D. Adverse effects occur more often and are more severe when you take only one antituberculotic medication.
Correct Answer: A
Rationale: Multiple medications prevent resistance in TB treatment, as Mycobacterium tuberculosis can quickly adapt to a single drug, necessitating a combination regimen.
Exhibit 1 Exhibit 2 Exhibit 3
Graphic Record
Heart rate 112/min
Blood pressure 122/60 mm Hg
Temperature 38.6° C (101.5° F)
Respiratory rate 24/min
A nurse is reviewing the medical record of a client who has pneumonia. Which of the following information is the priority for the nurse to report to the provider?
- A. Sputum results
- B. Creatinine level
- C. Temperature
- D. WBC count
Correct Answer: C
Rationale: Pneumonia, an acute respiratory infection, requires monitoring for signs of worsening condition or treatment response. The exhibit shows heart rate 112/min, blood pressure 122/60 mm Hg, temperature 38.6°C (101.5°F), and respiratory rate 24/min. Option C, temperature, is the priority 38.6°C indicates fever, a key sign of active infection or potential sepsis, especially with tachycardia (112/min) and tachypnea (24/min). This triad suggests systemic inflammatory response, needing urgent provider attention to adjust antibiotics or assess deterioration. Option A, sputum results, guides therapy but isn't immediately actionable without context. Option B, creatinine, monitors kidney function but isn't the acute priority here. Option D, WBC count, reflects infection severity but fever drives immediate concern. Elevated temperature, per triage protocols, signals potential escalation, making it the most critical to report for timely intervention.
A nurse is obtaining a sterile urine specimen from a client who has an indwelling urinary catheter. Identify the sequence the nurse should follow.
- A. Wipe the sample port with an alcohol wipe and let the alcohol dry.
- B. Clamp the catheter tubing distal to the sampling port for 15 min.
- C. Attach a sterile needleless syringe to the sample port and aspirate the specimen
- D. Document in the client's electronic medical record that the specimen was sent to the laboratory.
- E. Empty the urine into a sterile container labeled with the client identifiers
Correct Answer: B,A,C,E,D
Rationale: Sequence: Clamp tubing (B) to collect urine, wipe port (A), aspirate with syringe (C), transfer to container (E), and document (D) for a sterile specimen.
History and Physical
1000:
Client reports generalized weakness and increased fatigue over the past few months.
Client states they become short of breath after climbing a flight of stairs and are having difficulty keeping up with their grandchildren.
History of rheumatoid arthritis. Reports taking naproxen 500 mg twice a day.
Client reports they follow a vegan diet.
Denies pain or discomfort.
Bilateral breath sounds clear and present throughout.
Mucous membranes pale.
Apical pulse rapid, regular.
Diagnostic Results
1000:
Hct 24% (37% to 47%)
Hgb 8 g/dL (12 to 16 g/dL)
RBC count 3 x 10 ⁶ pL (4.2 to 5.4 x 10 ⁶ pL)
Ferritin 8 ng/mL (10 to 150 ng/mL)
WBC count 9,000/mm ³ (5,000 to 10,000/mm ³)
Platelet count 180,000/mm ³ (150,000 to 400,000/mm ³)
Vitamin B ₁₂ 159 pg/mL (160 to 950 pg/mL)
Complete the following sentence by using the lists of options.The first action the nurse should take is to followed by (Client with low Hct, Hgb, vegan diet)
- A. reinforce education about nutritional supplements
- B. collecting data about nutritional intake
- C. administer IV fluids
- D. notify the provider
- E. monitor vital signs
- F. prepare for transfusion
- G. document findings
Correct Answer: B,A
Rationale: Collecting nutritional data identifies deficiencies (e.g., B12, iron from vegan diet), followed by education on supplements.
NURSES’ NOTES
1000:
Client reports that over the past 2 months they have noticed multiple changes with their body. They have a decrease in activity tolerance, feel tired all the time, and have had difficulty remembering things. The client also states they bruise easily, are experiencing constipation, and they no longer tolerate the cold like they used to.
Client states they are concerned about exposure to seasonal viruses from other patrons.
Reports that they are currently experiencing a headache with a pain of 3 on a scale of 0 to 10.
Actions to Take
• Limit caffeine intake.
• Observe the need to administer sumatriptan.
• Withhold lithium.
Potential Condition
• Influenza
• Lithium toxicity
• Migraine
Parameters to Monitor
• Flashing lights
• Blurred vision
• Chest pain
A nurse in a provider's office is caring for a client who reports changes in their health over the past 2 months. What condition is the client most likely experiencing?
- A. Influenza
- B. Lithium toxicity
- C. Migraine
- D. Hypothyroidism
Correct Answer: D, A
Rationale: Symptoms like decreased activity tolerance, fatigue, memory issues, bruising, constipation, and cold intolerance over 2 months suggest hypothyroidism thyroid hormone deficiency slows metabolism, causing systemic effects. Influenza is acute, with fever and respiratory symptoms, not chronic fatigue or bruising. Lithium toxicity includes tremor or confusion, but not cold intolerance or constipation as primary signs. Migraine causes headaches (here, 3/10), but not multisystem changes like bruising or memory loss. Hypothyroidism fits the gradual onset and constellation fatigue from low energy, memory fog from cerebral hypoperfusion, and constipation from sluggish gut motility requiring thyroid function tests (e.g., TSH), making it the most likely condition.