Nokea
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.
For each potential provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client. Prescription: Administer an iron supplement.
- 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:
Rationale: Low Hct, Hgb, and ferritin indicate iron deficiency anemia, making iron supplementation anticipated.
You may also like to solve these questions
A nurse is providing first aid for a client who has a minor burn on one hand. Which of the following actions should the nurse take? (Select all that apply.)
- A. Maintain skin integrity over the blisters
- B. Apply ice to the larger blisters.
- C. Administer ibuprofen for pain.
- D. Run cool water over the affected area.
- E. Allow the affected area to remain open to air.
Correct Answer: A,C,D
Rationale: Blister integrity (A), pain relief with ibuprofen (C), and cool water (D) are correct. Ice can worsen damage, and open air isn't recommended initially.
A nurse is reinforcing teaching with a client who is taking enoxaparin. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will use ibuprofen when I have a headache.
- B. I will use an electric razor for shaving
- C. I will avoid the use of stool softeners.
- D. I will massage the site after each injection.
Correct Answer: B
Rationale: Using an electric razor reduces bleeding risk with enoxaparin, an anticoagulant. Ibuprofen increases bleeding, stool softeners may be needed, and massaging injection sites is contraindicated.
A nurse is assisting with the plan of care for an older adult client who has a new prescription for transdermal clonidine. Which of the following information should the nurse include in the plan of care?
- A. Advise the client about increased dry mouth.
- B. Monitor the client for weight loss.
- C. Inform the client of the adverse effect of diarrhea.
- D. Check the client for increased hypopigmentation under the patch.
- E. Monitor for hypertension.
- F. Advise about insomnia.
- G. Check for tachycardia.
Correct Answer: A
Rationale: Dry mouth is a common side effect of clonidine; diarrhea and hypopigmentation aren't typical.
A nurse is reviewing vital signs obtained by an assistive personnel on a group of clients. The previous vital signs for each of the clients were obtained 4 hr earlier. Which of the following changes should the nurse identify as the priority finding?
- A. Heart rate change from 110/min to 68/min
- B. Respiratory rate change from 12/min to 20/min
- C. Blood pressure change from 118/78 mm Hg to 86/50 mm Hg
- D. Temperature change from 36.6°C (97.9°F) to 38.8°C (101.9°F)
Correct Answer: C
Rationale: Using the ABCs, blood pressure dropping from 118/78 to 86/50 mm Hg signals potential shock or hypoperfusion, a circulation emergency requiring immediate assessment. Heart rate falling from 110 to 68 could reflect recovery (e.g., post-tachycardia) or bradycardia, but without symptoms, it's less urgent. Respiratory rate rising from 12 to 20 suggests compensation or distress, but circulation trumps breathing in acuity here. Temperature jumping to 38.8°C indicates fever, possibly infection, but hemodynamic instability is more immediately life-threatening. A systolic drop to 86 mm Hg risks organ perfusion, aligning with triage priorities hypotension could stem from bleeding, dehydration, or sepsis, needing rapid provider notification. This finding drives urgent intervention, making it the nurse's top concern.
A nurse is preparing to administer warfarin to a client who has chronic atrial fibrillation. Which of the following laboratory values should the nurse monitor prior to administering the medication?
- A. LDL
- B. INR
- C. BUN
- D. Hct
Correct Answer: B
Rationale: INR (International Normalized Ratio) measures clotting time and must be monitored with warfarin to ensure therapeutic anticoagulation and prevent bleeding or clotting complications in atrial fibrillation.