A nurse is caring for a patient with a BMI of.
Appropriate nursing interventions include:

Hourly vital signs.

Implementing all fall risk precautions.

Utilizing bariatric bed and trapeze bar.

Supine positioning.

Answer and Explanation

The Correct Answer is C

A patient with a BMI of 38 is considered to have obesity, which means they have excess body fat that may impair their mobility and increase their risk of complications such as pressure ulcers, infections, and respiratory problems. A bariatric bed is designed to accommodate the weight and size of obese patients, and a trapeze bar can help them change positions and transfer to a chair or wheelchair.

These interventions can promote comfort, safety, and independence for the patient.

Choice A is wrong because hourly vital signs are not necessary for a patient with obesity unless they have other conditions that warrant frequent monitoring.

Choice B is wrong because implementing all fall risk precautions may be excessive and restrictive for a patient with obesity who is otherwise stable and alert.

Choice D is wrong because supine positioning can compromise the patient’s breathing and circulation, and increase the risk of pressure ulcers and aspiration.

The patient should be encouraged to change positions frequently and elevate the head of the bed when lying down.

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Correct Answer is A

Explanation

Pursed-lip breathing is a technique that helps to slow down the breathing rate and keep the airways open longer. This improves gas exchange and reduces the work of breathing. Pursed-lip breathing also helps to prevent air trapping and hyperinflation of the lungs, which are common complications of COPD.

Choice B is wrong because laying down for 1 hour after meals can increase the pressure on the diaphragm and make breathing more difficult. It can also increase the risk of aspiration and reflux.

Choice C is wrong because restricting the client’s fluid intake to less than 1 L/day can lead to dehydration and thickening of secretions, which can obstruct the airways and impair gas exchange. Fluid intake should be adequate to maintain hydration and thin secretions.

Choice D is wrong because using the upper chest for respiration is a sign of inefficient breathing and respiratory distress.

It can increase the oxygen demand and cause fatigue. The client should be encouraged to use the diaphragm and abdominal muscles for respiration, which are more efficient and reduce the work of breathing.

Normal ranges for oxygen saturation are 95% to 100%, for arterial blood gas pH are 7.35 to 7.45, for PaCO2 are 35 to 45 mmHg, for PaO2 are 80 to 100 mmHg, and for HCO3 are 22 to 26 mEq/L.

A. Bradypnea. B. Tachycardia. C. Nail bed pallor. D. Pallor of conjunctiva.

Correct Answer is ["B","C","D"]

Explanation

These are signs of anemia, which is a condition in which the blood lacks enough healthy red blood cells to carry adequate oxygen to the body’s tissues.

Anemia can cause fatigue, weakness, pale skin, cold hands and feet, dizziness, reduced immunity and shortness of breath.

Choice A is wrong because bradypnea is abnormally slow breathing, which is not a sign of anemia. Anemia can cause tachypnea, which is abnormally fast breathing.

Choice E is wrong because flushed skin is not a sign of anemia. Anemia can cause pallor, which is pale or yellowish skin.

Flushed skin can be a sign of other conditions, such as fever, infection or allergic reaction.

Normal ranges for hemoglobin levels vary depending on age and gender. For adult males, the normal range is 13.5 to 17.5 grams per deciliter (g/dL) of blood. For adult females, the normal range is 12 to 15.5 g/dL of blood.

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A nurse is caring for a patient with a BMI of. Appropriate nursing interventions include:

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Explanation

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Correct Answer is ["B","C","D"]

Explanation

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A nurse is caring for a patient with a BMI of.
Appropriate nursing interventions include: