The nurse is caring for an obese patient who is suffering from fatigue related to ineffective breathing. Which intervention would be most appropriate to promote sleep?
Stopping smoking immediately
Running 30 minutes every morning
Limiting the diet to 1500 calories a day
Sleeping on two to three pillows at night
The Correct Answer is D
Choice A reason: Stopping smoking is beneficial for lung health but does not directly address immediate fatigue from ineffective breathing during sleep. Elevating the head improves airway patency overnight, providing faster relief for sleep-related breathing issues, making this less effective.
Choice B reason: Running 30 minutes daily is inappropriate for an obese patient with fatigue and ineffective breathing, as it may exacerbate respiratory strain. Elevating the head during sleep directly improves oxygenation, making exercise a long-term rather than immediate solution for sleep promotion.
Choice C reason: Limiting diet to 1500 calories addresses obesity but not acute fatigue from ineffective breathing during sleep. Sleeping with pillows elevates the head, reducing airway obstruction and improving rest, making dietary changes a secondary intervention for this specific issue.
Choice D reason: Sleeping on two to three pillows is the most appropriate intervention, as it elevates the head, reducing airway collapse in obese patients with ineffective breathing. This promotes better oxygenation during sleep, alleviating fatigue, making it the most effective immediate strategy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Placing a blanket over the feet may provide warmth but does not address the impaired circulation caused by tight restraints. Cool, pale extremities and delayed capillary refill indicate compromised blood flow, requiring immediate restraint adjustment, making this choice less urgent.
Choice B reason: A complete head-to-toe assessment is thorough but delays addressing the critical circulatory compromise indicated by cyanotic nail beds and prolonged capillary refill. Loosening restraints is the priority to restore blood flow, making this choice secondary.
Choice C reason: Loosening the restraints is the first action, as tight restraints likely cause impaired circulation, evidenced by cool, pale extremities, cyanosis, and capillary refill >5 seconds. Restoring blood flow prevents tissue damage, making this the priority intervention for patient safety.
Choice D reason: Assessing blood pressure and respiratory rate is important but not the first action. The localized circulatory issue from restraints requires immediate correction to prevent ischemia, making this choice less urgent than loosening the restraints.
Correct Answer is C
Explanation
Choice A reason: A 3-inch needle is too long for most IM injections; 1–1.5 inches is standard for adults. This risks hitting bone or tissue, making this incorrect for safe injection.
Choice B reason: IM injections require a 90-degree angle to reach muscle. A 45-degree angle is for subcutaneous injections, making this incorrect for intramuscular administration technique.
Choice C reason: Aspirating before injecting ensures the needle is not in a blood vessel, preventing intravenous administration. This safety step is standard for IM injections, making it correct.
Choice D reason: Massaging the site can cause medication leakage or tissue damage. Gentle pressure is preferred, making massage incorrect for post-injection care in IM administration.
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