The client problem of Activity Intolerance related to hypoxemia from sickling RBCs has been made for a client with sickle cell anemia. Which intervention should the nurse include in the plan of care? (SELECT ALL THAT APPLY)

Allow for rest periods between activities throughout the day

Provide supplemental oxygen when the pulse oximetry falls below 96%

Perform serial neurologic assessments to maintain safety and prevent injury

Assess ability to perform activities of daily living (ADLS)

Monitor blood pressure, pulse and respirations after activity

Answer and Explanation

Correct Answer : A,B,C,D,E

A) Allow for rest periods between activities throughout the day: This intervention is essential for a client with activity intolerance. Incorporating rest periods helps to manage fatigue and allows for recovery, particularly when hypoxemia is a concern due to sickle cell anemia.
B) Provide supplemental oxygen when the pulse oximetry falls below 96%: Administering supplemental oxygen when oxygen saturation levels drop below 96% is crucial for preventing further hypoxemia and ensuring adequate tissue perfusion, thus addressing the client's activity intolerance.

C) Perform serial neurologic assessments to maintain safety and prevent injury: Regular neurologic assessments are vital, especially in clients with sickle cell anemia, who are at risk for complications like stroke. This intervention helps monitor for changes in neurological status, ensuring prompt action if needed.

D) Assess ability to perform activities of daily living (ADLs): Evaluating the client’s ability to perform ADLs provides valuable information on their functional status and helps tailor interventions to promote independence while considering their limitations due to hypoxemia.

E) Monitor blood pressure, pulse, and respirations after activity: This monitoring is important to evaluate the client’s response to activity and to detect any changes that could indicate distress or worsening hypoxemia. This information helps guide further interventions and ensures the client’s safety.

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Correct Answer is B

Explanation

A. "will confirm a diagnosis of G6PD anemia": This statement is incorrect. The Schilling test is specifically used to evaluate vitamin B12 absorption and diagnose conditions like pernicious anemia, not G6PD deficiency.

B. "is a 24-hour urine specimen collection test": This statement is accurate. The Schilling test typically involves collecting a 24-hour urine specimen to measure the amount of radioactively labeled vitamin B12 excreted in the urine, which helps determine if the body is absorbing vitamin B12 properly.

C. "involves limiting intake of animal proteins": This statement is misleading. While dietary restrictions may be necessary for certain tests, the Schilling test primarily focuses on the absorption of vitamin B12 and does not require limiting animal protein intake.

D. "entails administration of methylcellulose prior to the test": This statement is incorrect. Methylcellulose is not involved in the Schilling test. The test typically includes administration of oral vitamin B12 with or without intrinsic factor to evaluate absorption.

A. "You can take 81 mg of enteric coated aspirin with orange juice at lunch time B. "Take the aspirin with a glass of milk or food in the morning" C. "Take a baby aspirin with a full glass of cold water at bedtime." D. "It's ok to take the aspirin with some ginseng tea in the evening."

Correct Answer is B

Explanation

A) "You can take 81 mg of enteric coated aspirin with orange juice at lunch time": While enteric-coated aspirin can help reduce gastrointestinal irritation, taking it with orange juice is not advisable. Citrus can increase gastric acidity, which might irritate the GI tract further, especially in a patient with a history of GI bleeding.

B) "Take the aspirin with a glass of milk or food in the morning": This instruction is appropriate as taking aspirin with food or milk can help minimize gastrointestinal irritation and promote safer use, especially in a client with iron deficiency anemia from a GI bleed. It also helps with absorption and can reduce the risk of an upset stomach.

C) "Take a baby aspirin with a full glass of cold water at bedtime": Taking aspirin with only water, particularly at bedtime, may increase the risk of gastric irritation and does not provide the protective effect that food or milk would. This is not the best practice for someone with a history of GI issues.

D) "It's ok to take the aspirin with some ginseng tea in the evening": Ginseng can interact with blood-thinning medications and may increase bleeding risk. Advising the client to combine aspirin with ginseng tea could be harmful, especially given their history of GI bleeding. This is not a safe or appropriate recommendation.

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The client problem of Activity Intolerance related to hypoxemia from sickling RBCs has been made for a client with sickle cell anemia. Which intervention should the nurse include in the plan of care? (SELECT ALL THAT APPLY)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

In preparation for a client having a Schilling test the nurse should explain that the test:

Correct Answer is B

Explanation

The nurse is caring for a client diagnosed with iron deficiency anemia as the result of a gastrointestinal (GI) bleed. What discharge instruction should the nurse provide if this client is also prescribed aspirin 81 mg daily?

Correct Answer is B

Explanation

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