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A nurse in a provider's office is assisting in the care of a client. For each potential provider's prescription, which is anticipated for the client?
- A. Administer an iron supplement.
- B. Collaborate with a nutritional consultant.
- C. Place the client on a low sodium diet.
- D. Restrict fluid intake.
Correct Answer: A
Rationale: Given the client's vegan diet, fatigue, weakness, pale mucous membranes, and rapid pulse (Exhibit 1), iron deficiency anemia is likely. Administering an iron supplement is anticipated it corrects low hemoglobin, a common vegan shortfall without meat or fortified sources, directly addressing the suspected etiology. Nutritional consultation helps long-term, but immediate supplementation is urgent for symptom relief and oxygen delivery. A low-sodium diet suits heart failure or hypertension, not anemia blood pressure (132/60 to 102/50 mm Hg) reflects orthostasis, not sodium issues. Fluid restriction applies to fluid overload, not here, where hydration supports circulation. Iron supplementation aligns with anemia management guidelines (e.g., ferrous sulfate), offering rapid hematologic improvement, making it the expected prescription for this presentation.
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A nurse is caring for a client who has dysphagia following a stroke. When assisting the client at mealtime, which of the following actions should the nurse plan to take?
- A. Instruct the client to tilt their head back to facilitate swallowing
- B. Encourage the client to use a straw.
- C. Provide oral care before meals.
- D. Schedule physical therapy directly before meals.
Correct Answer: C
Rationale: Oral care before meals removes debris and reduces aspiration risk in dysphagia. Tilting back worsens swallowing, straws may not be safe, and therapy timing isn't relevant.
A nurse is caring for a client who is postoperative following the placement of a colostomy. Which of the following findings indicates the colostomy is functioning properly?
- A. Passing of flatus
- B. Stoma is pinkish-red
- C. Tolerating a clear liquid diet
- D. Absent bowel sounds
Correct Answer: A
Rationale: Passing flatus indicates the colostomy is functioning by expelling gas, a normal postoperative sign. Pink stoma and diet tolerance are positive but not definitive, and absent sounds suggest ileus.
A nurse is assisting in the care of a client who is postoperative following an open reduction internal fixation of the right tibia. The first action the nurse should take is to...
- A. notify the provider of increased pain followed by elevating the extremity at level of the heart.
- B. check the client's oxygen saturation followed by administering pain medication.
- C. assess the client's incision site followed by applying a cold pack.
- D. monitor the client's vital signs followed by documenting the findings.
Correct Answer: A
Rationale: Post-ORIF, increased pain (Day 2, 1600) suggests compartment syndrome, a surgical emergency requiring immediate provider notification to evaluate for fasciotomy. Elevating the extremity at heart level balances perfusion without worsening pressure, unlike high elevation which reduces blood flow. Checking oxygen saturation and medicating pain address symptoms, not the cause pain here signals ischemia, not hypoxia. Assessing the incision (e.g., swelling) supports suspicion, but notification trumps delay; cold packs may mask signs. Monitoring vital signs is routine, but pain's acuity demands action over documentation. Prompt reporting aligns with the 6 Ps, prioritizing limb salvage, making it the critical first step.
A nurse is caring for a client who has hypocalcemia. For which of the following findings should the nurse monitor?
- A. Tetany
- B. Increased blood pressure
- C. Decreased bowel sounds
- D. Lethargy
- E. Hypotension
- F. Dry skin
- G. Fever
Correct Answer: A
Rationale: Tetany (muscle spasms) is a classic sign of hypocalcemia due to nerve excitability.
A nurse in a long-term care facility is providing care for a client who has Alzheimer's disease and is agitated. Which of the following interventions should the nurse implement?
- A. Administer a prescribed oral dose of trazodone to the client.
- B. Encourage the client to ambulate with a staff member.
- C. Isolate the client in their room.
- D. Apply bilateral wrist restraints to the client.
Correct Answer: A
Rationale: Trazodone, if prescribed, can calm agitation in Alzheimer's safely. Ambulation may help but isn't immediate, isolation can worsen agitation, and restraints are a last resort.