The nurse develops an outcome statement for a male client with the nursing problem, ‘Activity intolerance.’ The plan of care includes progressive ambulation in the hallway with assistance. Which assessment best determines the client’s ability to tolerate this activity?

Client frequently says that he thinks he can continue.

Normal heart rate range before and after ambulation.

Stopping frequently to talk with others in the hallways.

A shuffling gait progresses to deliberate walking steps.

Answer and Explanation

The Correct Answer is B

Choice A reason: The client’s verbal assurance of continuing reflects motivation but not physiological tolerance. Activity intolerance is measured by objective signs like heart rate and respiratory response. Subjective statements may mask fatigue or distress, making this an unreliable indicator of the client’s ability to safely tolerate progressive ambulation.

Choice B reason: A normal heart rate range before and after ambulation indicates cardiovascular stability, a key marker of activity tolerance. Heart rate reflects the body’s response to physical demand. Stable rates suggest the client can handle ambulation without excessive strain, aligning with evidence-based assessment of endurance and safety in activity intolerance.

Choice C reason: Stopping frequently to talk may indicate social engagement or fatigue, not tolerance. Activity intolerance requires objective measures like heart rate or respiratory rate. Frequent stops could mask exertion or weakness, making this an ambiguous and unreliable assessment of the client’s ability to sustain ambulation safely.

Choice D reason: Progressing from a shuffling to deliberate gait suggests improved coordination but not necessarily activity tolerance. Gait quality does not directly measure cardiovascular or respiratory response to exertion. Heart rate stability is a more precise indicator of physiological tolerance, critical for assessing safety in clients with activity intolerance.

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Correct Answer is A

Explanation

Choice A reason: Washing with soap and water cleanses the skin, removing dirt, oils, and bacteria that could interfere with ointment absorption or cause infection. This method ensures a clean, intact surface, optimizing the medication’s efficacy. It is the standard, evidence-based preparation for topical administration, promoting safety and therapeutic effect.

Choice B reason: Cleansing with an alcohol prep pad is suitable for injections but may dry or irritate skin before ointment application. Alcohol removes natural oils, potentially reducing ointment absorption. Soap and water provide thorough cleansing without compromising skin integrity, making this a less appropriate method for topical medication preparation.

Choice C reason: Shaving excess hair may improve ointment contact but risks micro-abrasions, increasing infection risk. It is unnecessary unless hair significantly obstructs application. Washing with soap and water is sufficient to prepare the skin, ensuring cleanliness and safety without the potential complications associated with shaving.

Choice D reason: Gently massaging the area may enhance circulation but does not clean the skin, risking contamination or reduced ointment efficacy. Soap and water remove barriers to absorption, like oils or debris. Massage is not a standard preparation step, making it ineffective compared to thorough cleansing for topical administration.

A. Young adult client with chronic insomnia and atrial fibrillation being treated with warfarin. B. A client with restless leg syndrome and chronic obstructive pulmonary disease (COPD). C. An older adult client with multiple problems, including obesity, diabetes, and hypertension. D. A client who has a bleeding ulcer, high stress job, and takes flurazepam for sleep.

Correct Answer is C

Explanation

Choice A reason: Chronic insomnia and atrial fibrillation are not direct risk factors for sleep apnea. Warfarin treats clotting but does not affect airway obstruction. Sleep apnea is linked to obesity and anatomical factors, making this client less likely to require regular nighttime assessments compared to an obese, hypertensive client.

Choice B reason: Restless leg syndrome and COPD affect sleep and breathing but are not primary sleep apnea risk factors. COPD causes chronic airflow limitation, not intermittent airway collapse like apnea. Obesity is a stronger predictor, making the obese client with comorbidities a higher priority for regular sleep apnea assessments.

Choice C reason: Obesity, diabetes, and hypertension are strongly associated with obstructive sleep apnea, as excess weight narrows airways, causing intermittent collapse during sleep. Older adults are at higher risk due to reduced muscle tone. Regular nighttime assessments for snoring or apneic episodes are critical to detect and manage this condition, per evidence-based guidelines.

Choice D reason: A bleeding ulcer, high stress, and flurazepam use may disrupt sleep but are not specific to sleep apnea. Flurazepam, a sedative, may worsen undiagnosed apnea by relaxing airway muscles. Obesity remains a stronger risk factor, making the obese client with comorbidities the priority for regular apnea assessments.

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The nurse develops an outcome statement for a male client with the nursing problem, ‘Activity intolerance.’ The plan of care includes progressive ambulation in the hallway with assistance. Which assessment best determines the client’s ability to tolerate this activity?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which is the best method for the nurse to use to prepare the skin prior to administration of a topical ointment?

Correct Answer is A

Explanation

The nurse is planning care for a group of clients during the night shift on a medical unit. Which client should be assessed regularly during the night for sleep apnea?

Correct Answer is C

Explanation

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