A nurse is contributing to the plan of care for a client who has leukemia and is experiencing chronic fatigue.
Which of the following interventions should the nurse plan to include?
Increase protein in the diet.
Increase the client's fluids to 4 L per day.
Encourage the client to have continual bed rest.
Encourage strength-training exercise.
The Correct Answer is A
A. Protein supports tissue repair, maintains muscle mass, and provides sustained energy. Leukemia and its treatments can lead to muscle wasting and general weakness, so additional protein can help counteract these effects and improve energy levels. It is also essential for immune support as well.
B. Increasing fluids to 4 L per day is generally excessive and may not be appropriate for this client. Excessive fluid intake can place strain on the cardiovascular system, which could be problematic, especially if the client is receiving chemotherapy or other treatments that may impact fluid balance.
C. Continual bed rest is not recommended, as it can contribute to deconditioning, muscle atrophy, and worsening fatigue over time. While rest periods are essential for clients experiencing fatigue, it is equally important to incorporate balanced, low-intensity activity to maintain strength and circulation.
D. Such exercises require significant energy and exertion, which might not be tolerable and could exacerbate fatigue. Instead, gentle, low-impact activities like walking or stretching are more appropriate for maintaining function without overwhelming the client’s energy reserves.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C"]
Explanation
A. Create an opening on the skin barrier that is 1.27 cm (0.5 in) larger than the client's stoma.The opening on the skin barrier should be cut to fit closely around the stoma, approximately 0.3-0.6 cm (1/8 to 1/4 inch) larger than the stoma size. A larger opening (like 0.5 inches) could expose too much surrounding skin, increasing the risk of skin irritation from contact with the stoma's effluent.
B. Use a moisturizing soap to clean the skin around the client's stoma.Moisturizing soaps should be avoided because they can leave a residue on the skin, which may interfere with the adhesion of the ostomy appliance. The skin around the stoma should be cleaned with mild soap and water, or water alone, and then dried thoroughly before applying the new appliance.
C. Empty the client's ostomy pouch before removing the skin barrier.Emptying the ostomy pouch before removing the skin barrier is a practical step to reduce spillage of stool during the appliance change, making the process cleaner and easier to manage. It also minimizes the risk of contamination of the surrounding area or wound.
D. Change the client's ostomy appliance 1 hour after breakfast.Ostomy appliances are best changed when the bowel is least active, which is usually before a meal or several hours after eating. Changing the appliance shortly after a meal, such as 1 hour after breakfast, may result in more stoma output, making it harder to manage the appliance change.
Correct Answer is C
Explanation
The shoulder harnesses of the car seat should be adjusted to fit the infant properly. The straps should be positioned at or below the level of the infant's shoulders to ensure a secure fit and proper restraint.
Infants should always be placed in a rear-facing car seat in the back seat of the vehicle. If the car seat is placed in the front seat, the airbag should be turned off to prevent potential harm to the infant in case of airbag deployment.
Do not put a small cushion under the newborn's head for support: It is important to follow the manufacturer's guidelines for the specific car seat being used. Additional cushions or supports should not be added to the car seat as they can interfere with the proper fit and safety of the seat. The infant's head should be supported by the car seat itself.
Infants should be placed in a rear-facing car seat at a reclined angle of approximately 45 degrees. This helps to keep the infant's airway open and provides proper support for their head and neck.
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