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 D

Explanation

A) Reassuring the client that they will be able to do the exercise program: While reassurance is important for motivation, it does not provide practical support or help the client engage effectively in the program.

B) Explaining the exercise program to the client's spouse: While involving the spouse can be beneficial, the primary focus should be on ensuring the client understands and can engage in the program themselves.

C) Providing the client with specific details of how to perform the exercises: While it's important for the client to understand the exercises, simply giving details may not address the client's personal preferences or limitations, which are crucial for adherence.

D) Adapting the program to the client's needs and abilities: This intervention is the best approach to help the client maintain the exercise program. By tailoring the exercise regimen to fit the client's individual abilities, preferences, and any physical limitations, the client is more likely to feel confident, motivated, and able to stick with the program long-term.

A. 2 inches 21 gauge B. 1 1/2 inch 27 gauge C. 5/8 inch 25 gauge D. 1/4 inch 19 gauge

Correct Answer is C

Explanation

A. 2 inches 21 gauge: This option is too long and too large in gauge for subcutaneous administration. Typically, a longer needle is not necessary for subcutaneous injections, especially for standard adult adipose tissue.

B. 1 1/2 inch 27 gauge: While this gauge is acceptable, the length is still longer than typically required for subcutaneous injections. A 1 1/2 inch needle is more suited for intramuscular injections.

C. 5/8 inch 25 gauge: This is the most appropriate choice for a subcutaneous injection. A 5/8 inch needle is typically adequate for subcutaneous tissue in adults, and a 25 gauge needle provides a suitable size for comfort while allowing the medication to be administered effectively.

D. 1/4 inch 19 gauge: This option is not suitable for subcutaneous injections. A 1/4 inch length is too short for effective penetration into subcutaneous tissue, and a 19 gauge needle is larger than necessary, which could increase discomfort.

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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

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