Nokea
Vital Signs
1000:
Temperature 37° C (98.6° F)
Blood pressure 132/60 mm Hg right arm supine
Blood pressure 118/60 mm Hg right arm sitting
Blood pressure 102/50 mm Hg right arm standing
Heart rate 108/min
Respiratory rate 24/min
Pulse oximetry 94% on room air
Nurses Notes
1100:
Reinforced education about iron supplements and dietary recommendations.
Which of the following instructions should the nurse include? (Client with iron deficiency anemia)
- A. Take an antacid within 30 min after medication
- B. Increase sources of fiber in the diet.
- C. Take the medication with a source of vitamin C
- D. Take the medication on an empty stomach.
- E. Increase intake of milk and dairy products.
- F. Expect immediate energy improvement.
- G. Avoid green leafy vegetables.
Correct Answer: B,C,D
Rationale: Fiber prevents constipation, vitamin C enhances absorption, and empty stomach improves uptake; antacids and dairy reduce absorption.
You may also like to solve these questions
A nurse is assisting with the care of a client who is receiving peritoneal dialysis. Which of the following actions should the nurse take?
- A. Chill the dialysate prior to infusion.
- B. Monitor the client for diarrhea.
- C. Weigh the client before and after the treatment.
- D. Use clean gloves when handling dialysate bags.
Correct Answer: C
Rationale: Weighing before and after tracks fluid removal in peritoneal dialysis, assessing treatment effectiveness. Dialysate is warmed, diarrhea isn't a primary concern, and sterile gloves are preferred.
A nurse is assisting with the transfer of a client from a medical-surgical unit to an intensive care unit following a change in status. Which of the following information should the nurse include in the transfer documentation?
- A. Number of family members who have visited
- B. Primary health problem
- C. Admission vital signs from 1 week ago
- D. Scheduled times for dressing changes
- E. Current medication prescriptions
Correct Answer: B
Rationale: Transfer documentation ensures continuity of care, focusing on critical, current data for the receiving team. The primary health problem is essential it summarizes why the client's status changed (e.g., respiratory failure, sepsis), guiding ICU interventions. Number of family members who visited is irrelevant to clinical management; it's a social detail, not a priority. Admission vital signs from a week ago are outdated current vitals matter more, especially with a status change. Scheduled dressing changes are useful but secondary to understanding the underlying condition driving the transfer. Identifying the primary issue provides context for the client's deterioration, aligns with handoff standards like SBAR (Situation, Background, Assessment, Recommendation), and ensures the ICU team addresses the root cause immediately. This focus on relevance enhances patient safety, reduces miscommunication, and supports rapid response in a critical setting, making it the most vital piece of transfer information.
A home health nurse is reinforcing teaching with an older adult client about safety precautions to take in the home. Which of the following instructions should the nurse include?
- A. Place white tape on the edges of stairs.
- B. Place area rugs on wooden floors.
- C. Run wires and cords under carpeting.
- D. Have the furnace inspected every 2 years.
Correct Answer: A
Rationale: White tape on stair edges improves visibility, reducing fall risk in older adults. Rugs and hidden cords are trip hazards, and furnace checks should be annual, not biennial.
A home health nurse is assisting in the care of a client following a modified radical mastectomy. Which of the following statements by the client indicates effective coping?
- A. I would like to see what this looks like today.
- B. I would just like to spend my day staring at the TV.
- C. I'm going to close my eyes until you are done dressing my incision.
- D. I'm planning to stay at home until my breast reconstructive surgery.
- E. I don't care about my appearance anymore.
- F. I'll never leave the house again.
- G. I feel fine and don't need help.
Correct Answer: A
Rationale: Wanting to see the incision shows acceptance and engagement in recovery; other options suggest avoidance or denial.
• Exhibit 1 Exhibit 2 Exhibit 3
• 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 finding, click to specify if the finding is consistent with sickle cell disease, iron deficiency anemia, and/or pernicious anemia. Each finding may support more than 1 disease process.
A nurse in a provider's office is assisting in the care of a client. For each finding, click to specify if the finding is consistent with sickle cell disease, iron deficiency anemia, and/or pernicious anemia. Which finding is most consistent with iron deficiency anemia?
- A. Ferritin level
- B. Fatigue
- C. Vitamin B level
- D. Orthostatic hypotension
Correct Answer: A
Rationale: Iron deficiency anemia stems from low iron, reducing hemoglobin synthesis, while sickle cell disease involves abnormal hemoglobin shape, and pernicious anemia results from Bâ‚â‚‚ malabsorption. Ferritin, the iron storage protein, is low in iron deficiency (e.g., <15 ng/mL), directly reflecting depleted reserves, as seen in the vegan client with fatigue and pale mucous membranes from Exhibit 1. Fatigue occurs across all three conditions nonspecific due to reduced oxygen delivery but isn't unique. Vitamin Bâ‚â‚‚ levels drop in pernicious anemia, not iron deficiency, unless dual deficiency exists, which isn't suggested. Orthostatic hypotension could arise in severe anemia from hypovolemia, but it's not specific to iron deficiency over others. Low ferritin aligns with iron deficiency's pathophysiology, distinguishing it from sickle cell's vaso-occlusion or pernicious anemia's megaloblastic changes, making it the most consistent finding per diagnostic criteria.