Question

A client has fatigue, temperature of 99.5° f (37.5° c), dark bronze skin, and dark urine. hemoglobin level 9 g/dl (90 g/l); hematocrit is 49 (0.49), and red blood cells are 2.75 million/µl (2.75 x 1012/l). what should the nurse do first?

a.place the client on bed rest.
b.place the client on contact isolation.
c.initiate an intake and output record.
d.keep the client out of sunlight.

Answer 1

The client's symptoms and lab results suggest a potential medical condition, such as hemolytic anemia, requiring the nurse to take immediate action based on the clinical context, which might include initiating an intake and output record or placing the patient on bed rest, as well as consulting with a physician for further assessment.

Step-by-step explanation:

A client presenting with symptoms such as fatigue, a slightly elevated temperature of 99.5° F (37.5° C), dark bronze skin, and dark urine, combined with a hemoglobin level of 9 g/dl (90 g/l), hematocrit of 49 (0.49), and red blood cell count of 2.75 million/μl (2.75 x 1012/l), suggests the possibility of an underlying medical condition, possibly hemolytic anemia or another blood disorder. With these clinical presentations and abnormal lab results, the most immediate action a nurse should take depends on the context of the findings and whether they indicate an acute medical emergency, a chronic condition, or the need for further diagnostic testing to determine the underlying cause.

However, without additional context from the presented options, other steps might be necessary, such as initiating an intake and output record to closely monitor the patient's fluid balance and potential renal involvement, or placing the patient on bed rest to minimize energy expenditure and oxygen consumption if the patient is hemodynamically unstable. Consultation with a physician for further assessment and possible referral to a hematologist or other specialist would likewise be prudent.

Answer 2

The answer is C
The nurse's first response is to begin an intake and output record. The client is showing signs of anemia with jaundice and exhibiting fluid imbalance. At this point, the client should not be placed on bed rest.The client is also not contagious and will be unnecessary if the client is placed on contact isolation. Client will not be affected by sunlight since he might have jaundice due to the changes of color of the urine and skin.