The nurse is providing for the hygiene needs of a client with an activity intolerance. Which is the priority nursing intervention?
Administering oxygen during provision of care
Assessing response to activity
Providing rest periods every ten minutes
Maintaining the bed in high-Fowler's position
The Correct Answer is B
B. Before, during, and after providing hygiene care, the nurse should continually assess the client's response to activity. Signs such as increased heart rate, shortness of breath, fatigue, or discomfort should be monitored closely. Assessing the client's response allows the nurse to adjust care activities as needed to prevent exacerbation of symptoms or complications.
A. Administering oxygen may be necessary if the client has respiratory compromise or if oxygen saturation levels are low during activities. However, this intervention should be based on the client's specific needs as assessed by the nurse and should not necessarily be a routine intervention
C Providing regular rest periods is an important intervention for clients with activity intolerance. However, the assessment will guide how and when these interventions should be implemented.
D. Fowler's position are also important, but the assessment will guide how and when these interventions should be implemented.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
D. Counting the radial pulse for 30 seconds and then multiplying the count by two gives an estimate of the client's heart rate per minute (bpm). This method is efficient and commonly used in clinical practice, especially if the client's pulse is regular.
A. Counting the radial pulse for two minutes is unnecessarily long and not standard practice. Typically, the radial pulse is counted for either 30 seconds or 60 seconds (one minute) to determine the client's heart rate. Multiplying the count by two for a 30-second count or directly using the count for a 60- second count provides the client's beats per minute (bpm).
B. The radial pulse is assessed by palpating the radial artery on the thumb side (or lateral side) of the client's wrist. The nurse places the index and middle fingers gently over the radial artery and applies light pressure to feel the pulse rhythm and rate.
C. Using the thumb to count the pulse is not recommended because the thumb has its own pulse, which could interfere with accurately assessing the client's radial pulse.
Correct Answer is ["A","B","C","E"]
Explanation
A. External rotation of the hip involves rotating the thigh outward away from the midline of the body. This movement occurs in the hip joint. External rotation is a component of hip range of motion.
B. Extension of the hip involves moving the thigh backward, straightening the leg from a flexed position. This movement also occurs in the hip joint. Extension is part of the hip's range of motion.
C. Adduction of the hip involves moving the thigh toward or across the midline of the body. It brings the leg closer to the midline. Adduction is another movement that is part of the hip's range of motion.
E. Flexion of the hip involves bringing the thigh toward the abdomen or bending the leg. It is a movement where the angle between the thigh and the abdomen decreases. Flexion is a fundamental movement of the hip joint.
D. Supination is a movement primarily associated with the forearm and hand, involving turning the palm upward or facing forward. It is not a movement of the hip joint. Supination is not correct in the context of hip range of motion.
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