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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Have biannual renal function studies: While monitoring renal function can be important, it is not specifically required for all patients on rosuvastatin. The focus should be on liver function and muscle-related side effects.
B. Stop the medication if you develop a headache: Headaches are not a common or serious side effect of rosuvastatin. Patients should not stop the medication without consulting their healthcare provider unless they experience severe symptoms.
C. Report muscle weakness or pain: This is critical information to provide. Statins, including rosuvastatin, can cause muscle-related side effects such as myopathy or rhabdomyolysis. Patients should be instructed to report any unexplained muscle weakness, pain, or tenderness.
D. Monitor body weight weekly: While maintaining a healthy weight is important, weekly weight monitoring is not a standard recommendation for patients taking rosuvastatin.
Correct Answer is ["480"]
Explanation
To calculate the infusion rate, you need to determine the total volume to be infused and the time over which it will be infused.
Total volume to be infused = 200 mL
Time for infusion = 25 minutes
Infusion rate = Total volume / Time Infusion rate = 200 mL / 25 minutes = 8 mL/min
To convert this to mL/hour (since infusion pumps are typically set in mL/hour): Infusion rate = 8 mL/min × 60 minutes/hour = 480 mL/hour
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
