The client diagnosed with multiple sclerosis (MS) is at risk for fatigue. Which priority intervention would the nurse implement to address this issue?

Schedule activities late in day and in the evening

Provide supplemental oxygen when fatigued

Teach the importance of hot showers to help relax

Have the client prioritize activities for the day

Answer and Explanation

The Correct Answer is D

A. Schedule activities late in the day and in the evening:

Scheduling activities late in the day is not an ideal approach for managing fatigue in clients with MS. Fatigue typically worsens as the day progresses, and clients with MS often experience more energy depletion in the late afternoon and evening. Therefore, the best time to schedule demanding activities is earlier in the day when the client may have more energy. Scheduling strenuous tasks late in the day may exacerbate fatigue and lead to physical and emotional exhaustion.

B. Provide supplemental oxygen when fatigued:

While oxygen therapy is appropriate for clients with respiratory issues or other conditions that affect oxygenation, it is not the most relevant intervention for addressing fatigue in MS. Fatigue in MS is primarily caused by neurological factors, muscle weakness, or impaired mobility, not by a lack of oxygen. The priority for MS-related fatigue is managing energy levels through activity planning and rest, not providing supplemental oxygen unless there is a specific indication of respiratory distress or hypoxia.

C. Teach the importance of hot showers to help relax:

Hot showers may help some individuals relax, but they are not the best intervention for managing fatigue in MS. In fact, heat can sometimes worsen symptoms in clients with MS, a phenomenon known as Uhthoff’s phenomenon, where heat increases neurological symptoms such as muscle weakness, fatigue, or visual disturbances. It is important to educate clients to avoid overheating, which could exacerbate fatigue or other symptoms. Instead, clients should focus on rest, energy conservation, and temperature regulation.

D. Have the client prioritize activities for the day: Fatigue is a common and debilitating symptom in clients with multiple sclerosis (MS), and it can significantly affect their daily functioning. One of the most effective interventions for managing fatigue in MS is to encourage the client to prioritize activities and manage their energy levels throughout the day. By scheduling the most important or demanding tasks earlier in the day when energy levels tend to be higher, clients can conserve energy for essential activities. Additionally, teaching clients to break tasks into smaller, manageable steps and incorporating frequent rest periods can help minimize fatigue and prevent overexertion. Prioritizing activities ensures that the client is not overwhelmed and can still maintain independence while managing their symptoms effectively.

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Free Nursing Study Resources

Correct Answer is ["56"]

Explanation

Calculate the infusion rate in mL/min.

The total volume to be infused is 500 mL.

The infusion time is 90 minutes.

The infusion rate = 500 mL / 90 minutes = 5.5556 mL/min.

Calculate the drip rate in gtt/min.

The drop factor is 10 gtt/mL.

We need to deliver 5.5556 mL/min.

To find the drip rate, we can set up a proportion:

10 gtt / 1 mL = x gtt / 5.5556 mL

Cross-multiplying:

x = 10 gtt/mL x 5.5556 mL = 55.5556 gtt

Round the answer to the nearest whole number.

56 gtt/min.

A. Monitor the client's pulse oximetry every shift B. Assess the client's respiratory status at least every 1-2 hours C. Ensure that a manual resuscitation bag is at the bedside D. Check the ventilator settings every shift E. Collaborate frequently with the respiratory therapist

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

Explanation

A) Monitor the client's pulse oximetry every shift:
Monitoring pulse oximetry every shift is not sufficient when caring for a client on a ventilator. Pulse oximetry provides valuable information about oxygen saturation, but it should be checked more frequently, especially in a critically ill patient on a ventilator. Continuous monitoring may be required to ensure that oxygenation is maintained at optimal levels. The nurse should assess the pulse oximetry regularly and take immediate action if there is a significant change in the client’s oxygen saturation.

B) Assess the client's respiratory status at least every 1-2 hours:
It is essential to assess the client's respiratory status frequently when they are on a ventilator. Respiratory assessments should be performed at least every 1-2 hours to monitor for complications such as ventilator-associated pneumonia, changes in oxygenation, or the need for adjustments to the ventilator settings. Regular assessment is critical to detect early signs of deterioration and respond promptly.

C) Ensure that a manual resuscitation bag is at the bedside:
Having a manual resuscitation bag (e.g., Ambu bag) at the bedside is a critical intervention for clients on a ventilator. In case of ventilator malfunction, extubation, or respiratory distress, the nurse must have immediate access to a resuscitation bag to manually ventilate the patient. This is a lifesaving piece of equipment that should always be present and ready for use.

D) Check the ventilator settings every shift:
It is essential to check ventilator settings every shift to ensure that the ventilator is functioning correctly and providing the appropriate levels of support for the patient. This includes checking settings such as tidal volume, respiratory rate, pressure, and FiO2 (fraction of inspired oxygen) to ensure they are appropriate for the client's condition. Regular checks can help detect problems such as changes in settings or malfunctioning equipment.

E) Collaborate frequently with the respiratory therapist:
Frequent collaboration with the respiratory therapist is crucial when managing a client on a ventilator. Respiratory therapists are experts in ventilator management and can provide valuable insight into adjusting settings, interpreting ABGs, troubleshooting equipment issues, and optimizing respiratory care. Collaborative care helps ensure that the client is receiving the most appropriate interventions and adjustments for their respiratory status.

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The client diagnosed with multiple sclerosis (MS) is at risk for fatigue. Which priority intervention would the nurse implement to address this issue?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient is prescribed 500 ml of Normal Saline to be infused over 90 minutes. The drop factor on the tubing is 10 gtt/mL. At what rate should the nurse regulate the IV (gtt/min)? (Round to the nearest whole number)

Correct Answer is ["56"]

Explanation

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Explanation

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