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NurseDive Free Nursing Practice Question
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)
A. Allow for rest periods between activities throughout the day
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%
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
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)
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
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.
This question is an excerpt from Nurse Dive's nursing test bank - ATI n200 Pharmacology Proctored Exam. Take the full exam now
Full Explanation
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.
Similar Questions
A 10-year-old with Attention Deficit-Hyperactivity Disorder (ADHD) evaluated at the mental health clinic is exhibiting hyperactivity and distractibility. After 5 weeks of methylphenidate, the nurse should monitor for which desired outcome? (SELECT ALL THAT APPLY)
A. working on an arithmetic quiz for 20 minutes without getting out of their seat
Working on an arithmetic quiz for 20 minutes without getting out of their seat: This outcome indicates improved focus and attention span, which are desired effects of methylphenidate in managing ADHD symptoms. The ability to stay seated and concentrate on a task for an extended period is a positive sign of the medication’s effectiveness.
B. family members report no episodes of pica
Family members report no episodes of pica: Pica, the consumption of non-food items, is not typically associated with ADHD. Therefore, the absence of pica episodes is not a relevant outcome for evaluating the effectiveness of methylphenidate in this context.
C. does not tell untrue information
Does not tell untrue information: While honesty is important, it is not a primary focus of ADHD treatment. Methylphenidate aims to improve attention, focus, and reduce hyperactivity, rather than directly addressing truthfulness.
D. completing a jigsaw puzzle with a friend
Completing a jigsaw puzzle with a friend: Successfully completing a jigsaw puzzle with a friend demonstrates improved attention, focus, and social interaction skills. These are positive outcomes of methylphenidate treatment for ADHD, indicating better management of hyperactivity and distractibility.
E. decreased manipulative behaviors
Full Explanation
A) Working on an arithmetic quiz for 20 minutes without getting out of their seat: This outcome indicates improved focus and attention span, which are desired effects of methylphenidate in managing ADHD symptoms. The ability to stay seated and concentrate on a task for an extended period is a positive sign of the medication’s effectiveness.
B) Family members report no episodes of pica: Pica, the consumption of non-food items, is not typically associated with ADHD. Therefore, the absence of pica episodes is not a relevant outcome for evaluating the effectiveness of methylphenidate in this context.
C) Does not tell untrue information: While honesty is important, it is not a primary focus of ADHD treatment. Methylphenidate aims to improve attention, focus, and reduce hyperactivity, rather than directly addressing truthfulness.
D) Completing a jigsaw puzzle with a friend: Successfully completing a jigsaw puzzle with a friend demonstrates improved attention, focus, and social interaction skills. These are positive outcomes of methylphenidate treatment for ADHD, indicating better management of hyperactivity and distractibility.
The nurse auscultates a heart murmur on a client with cardiovascular disease. At which anatomic landmark will an aortic murmur be heard the loudest?
A. Second Intercostal space right of sternum
Second intercostal space right of sternum: This is the correct location for auscultating an aortic murmur. The aortic area is best heard at the second intercostal space on the right side of the sternum, where the sound of blood flow through the aortic valve is most prominent.
B. Fourth intercostal space, left mid-clavicular line
Fourth intercostal space, left mid-clavicular line: This location is typically associated with the mitral valve area, not the aortic area. While important for other heart sounds, it does not correspond to where an aortic murmur would be heard loudest.
C. Third intercostal space, left of sternum
Third intercostal space, left of sternum: This area is generally associated with the pulmonic area, not the aorta. Murmurs from the aortic valve would not be best heard here.
D. Second intercostal space left of sternum
Second intercostal space left of sternum: This location is associated with the pulmonic area as well. An aortic murmur would not be best auscultated here, making this option incorrect for identifying an aortic murmur specifically.
Full Explanation
A) Second intercostal space right of sternum: This is the correct location for auscultating an aortic murmur. The aortic area is best heard at the second intercostal space on the right side of the sternum, where the sound of blood flow through the aortic valve is most prominent.
B) Fourth intercostal space, left mid-clavicular line: This location is typically associated with the mitral valve area, not the aortic area. While important for other heart sounds, it does not correspond to where an aortic murmur would be heard loudest.
C) Third intercostal space, left of sternum: This area is generally associated with the pulmonic area, not the aorta. Murmurs from the aortic valve would not be best heard here.
D) Second intercostal space left of sternum: This location is associated with the pulmonic area as well. An aortic murmur would not be best auscultated here, making this option incorrect for identifying an aortic murmur specifically.
The nurse calculates that 8 ml of cefazolin is to be drawn from a vial after reconstitution. The instructions state that the medication is to be further diluted in 50 mls of NSS for IV administration and to run over 30 minutes. At what rate will the nurse set to infusion pump to deliver the medication?
Full Explanation
To calculate the infusion rate, we'll follow these steps:
Determine the total volume to be administered:
8 mL (drawn from the vial) + 50 mL (dilution with NSS) = 58 mL
Calculate the infusion rate:
58 mL ÷ 30 minutes = 1.93 mL/minute
Convert mL/minute to mL/hour:
1.93 mL/minute × 60 minutes/hour = 116 mL/hour