For a client diagnosed with folic acid deficiency anemia who is experiencing activity intolerance, what should the nurse include in the plan of care?

Provide a quiet atmosphere for undisturbed sleep.

Cluster activities in the morning when well-rested.

Identify ways to conserve energy when performing activities.

Recommend small frequent iron-rich meals.

Answer and Explanation

The Correct Answer is C

Choice A Reason
Providing a quiet atmosphere for undisturbed sleep is beneficial for all patients, especially those recovering from illness. However, it does not directly address the issue of activity intolerance. Adequate rest is important, but the primary concern with activity intolerance is managing energy levels during waking hours to improve the patient's ability to engage in activities.

Choice B Reason
Clustering activities in the morning may seem like a good strategy when the patient is well-rested. However, this could lead to rapid depletion of energy reserves and exacerbate activity intolerance. It is more effective to spread activities throughout the day to manage energy levels better.

Choice C Reason
Identifying ways to conserve energy is a key intervention for managing activity intolerance. This can include teaching the patient energy-conservation techniques, such as sitting while showering or dressing, taking frequent breaks, and prioritizing tasks. This approach helps patients with folic acid deficiency anemia to participate in activities without excessive fatigue.

Choice D Reason
While nutrition is important in the management of anemia, recommending small frequent iron-rich meals does not directly address activity intolerance. Folic acid deficiency anemia requires dietary intake of folate-rich foods or supplements. Iron is important, but the focus for folic acid deficiency should be on folate.

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Correct Answer is B

Explanation

Choice A Reason
A blood pressure of 120/80 mmHg is considered within the normal range and is an ideal target for most individuals being treated for hypertension. This finding would not typically alert the nurse to a side effect of lisinopril.

Choice B Reason
Serum potassium of 5.5 mEq/L is higher than the normal range, which is typically between 3.5 and 5.0 mEq/L. Lisinopril can cause hyperkalemia, which is an elevated level of potassium in the blood. This is a known side effect of lisinopril, especially in clients with renal impairment, as it inhibits the renin-angiotensin-aldosterone system and reduces potassium excretion.

Choice C Reason
A heart rate of 80 beats per minute is within the normal range for adults, which is typically 60-100 beats per minute at rest. This finding would not alert the nurse to a side effect of lisinopril.

Choice D Reason
A respiration rate of 16 breaths per minute is within the normal range for adults, which is typically 12-20 breaths per minute at rest. This finding would not alert the nurse to a side effect of lisinopril.

A. Cyanosis noted in nail beds bilaterally. B. Lungs clear to auscultation. C. Inability to speak in full sentences. D. Pulse oximetry 94-96% on room air.

Correct Answer is ["B","D"]

Explanation

Choice A reason:
Cyanosis, or a bluish discoloration of the skin, particularly in the nail beds, is a sign of inadequate oxygenation and would not indicate successful intervention. The absence of cyanosis would be a positive outcome, reflecting improved oxygen saturation.

Choice B reason:
Lungs clear to auscultation would indicate that air is moving through all regions of the lungs without obstruction from fluid or mucus, which is a sign of recovery from pneumonia. This finding suggests that the interventions aimed at improving gas exchange, such as positioning, deep breathing exercises, and suctioning if needed, have been effective.

Choice C reason: The inability to speak in full sentences often indicates respiratory distress and would not be a sign of successful nursing intervention. An improvement would be the client's ability to speak in full sentences without difficulty, reflecting better lung function and gas exchange.

Choice D reason:
Pulse oximetry readings between 94-96% on room air are within normal limits and indicate adequate oxygen saturation and gas exchange. This is a clear sign that the client's respiratory status has improved, and the interventions for Impaired Gas Exchange have been successful.

Choice E reason:
Bronchovesicular breath sounds are normal breath sounds heard over the major bronchi and are typically moderate in pitch and intensity. However, they are not specifically indicative of successful intervention for Impaired Gas Exchange. The absence of abnormal sounds such as crackles or wheezes would be more relevant.

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For a client diagnosed with folic acid deficiency anemia who is experiencing activity intolerance, what should the nurse include in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is prescribed lisinopril 20 mg PO daily for the treatment of hypertension. Which finding would alert the nurse that a side effect of the medication has occurred?

Correct Answer is B

Explanation

A nurse implements a plan of care for a client with the problem of Impaired Gas Exchange as a result of left lower lobe pneumonia. Which findings would indicate that nursing interventions were successful? (Select all that apply)

Correct Answer is ["B","D"]

Explanation

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