The client diagnosed with multiple sclerosis (MS) is at risk for fatigue. Which priority intervention would the nurse implement to address this issue?

Schedule activities late in day and in the evening

Provide supplemental oxygen when fatigued

Teach the importance of hot showers to help relax

Have the client prioritize activities for the day

Answer and Explanation

The Correct Answer is D

A. Schedule activities late in the day and in the evening:

Scheduling activities late in the day is not an ideal approach for managing fatigue in clients with MS. Fatigue typically worsens as the day progresses, and clients with MS often experience more energy depletion in the late afternoon and evening. Therefore, the best time to schedule demanding activities is earlier in the day when the client may have more energy. Scheduling strenuous tasks late in the day may exacerbate fatigue and lead to physical and emotional exhaustion.

B. Provide supplemental oxygen when fatigued:

While oxygen therapy is appropriate for clients with respiratory issues or other conditions that affect oxygenation, it is not the most relevant intervention for addressing fatigue in MS. Fatigue in MS is primarily caused by neurological factors, muscle weakness, or impaired mobility, not by a lack of oxygen. The priority for MS-related fatigue is managing energy levels through activity planning and rest, not providing supplemental oxygen unless there is a specific indication of respiratory distress or hypoxia.

C. Teach the importance of hot showers to help relax:

Hot showers may help some individuals relax, but they are not the best intervention for managing fatigue in MS. In fact, heat can sometimes worsen symptoms in clients with MS, a phenomenon known as Uhthoff’s phenomenon, where heat increases neurological symptoms such as muscle weakness, fatigue, or visual disturbances. It is important to educate clients to avoid overheating, which could exacerbate fatigue or other symptoms. Instead, clients should focus on rest, energy conservation, and temperature regulation.

D. Have the client prioritize activities for the day: Fatigue is a common and debilitating symptom in clients with multiple sclerosis (MS), and it can significantly affect their daily functioning. One of the most effective interventions for managing fatigue in MS is to encourage the client to prioritize activities and manage their energy levels throughout the day. By scheduling the most important or demanding tasks earlier in the day when energy levels tend to be higher, clients can conserve energy for essential activities. Additionally, teaching clients to break tasks into smaller, manageable steps and incorporating frequent rest periods can help minimize fatigue and prevent overexertion. Prioritizing activities ensures that the client is not overwhelmed and can still maintain independence while managing their symptoms effectively.

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Correct Answer is A

Explanation

A. pH 7.44; PaO2 44 mmHg; PaCO2 35 mmHg; HCO3 25 mEq/L; O2 Sat 76%: This set of arterial blood gas (ABG) values is consistent with hypoxemic respiratory failure. Hypoxemic respiratory failure is characterized by a PaO2 less than 60 mmHg, and this client has a PaO2 of 44 mmHg, which is significantly below the normal range of 80-95 mmHg. Despite the fact that the client is on a 100% non-rebreather mask (which should ideally deliver high levels of oxygen), the low PaO2 suggests that oxygenation is not being effectively improved. Additionally, the low O2 saturation of 76% further supports the diagnosis of hypoxemic respiratory failure.

B. pH 7.30; PaO2 80 mmHg; PaCO2 62 mmHg; HCO3 25 mEq/L; O2 Sat 94%: This ABG indicates respiratory acidosis (pH is low, PaCO2 is elevated), but the PaO2 of 80 mmHg is within the normal range, and the O2 saturation of 94% is also normal. Respiratory acidosis with a normal PaO2 would indicate an issue with ventilation (hypoventilation), not hypoxemic respiratory failure. The patient is retaining CO2 but is still oxygenating well, so this result does not indicate hypoxemic respiratory failure.

C. pH 7.35; PaO2 65 mmHg; PaCO2 40 mmHg; HCO3 26 mEq/L; O2 Sat 90%: This result shows a PaO2 of 65 mmHg, which is mildly low but not sufficiently low to meet the criteria for hypoxemic respiratory failure (PaO2 should be below 60 mmHg for this diagnosis). The O2 saturation of 90% is also slightly low but not critically low. This client may have mild hypoxia but is not in respiratory failure based on these values.

D. pH 7.48; PaO2 75 mmHg; PaCO2 41 mmHg; HCO3 28 mEq/L; O2 Sat 93%: In this case, the PaO2 of 75 mmHg is slightly low but still within an acceptable range, and the O2 saturation of 93% is adequate. The elevated pH and normal PaCO2 suggest the presence of respiratory alkalosis (likely caused by hyperventilation). These ABG results are not consistent with hypoxemic respiratory failure, as the oxygen levels are still within a safe range.

A. Notify the health care provider B. Insert an oral airway to prevent the client from biting the tube C. Suction the client and reset the alarm D. Disconnect the client from the ventilator and use a manual resuscitation bag

Correct Answer is D

Explanation

A. Notify the healthcare provider: While notifying the healthcare provider may eventually be necessary, the first priority is to ensure the client's airway is protected and they are receiving adequate ventilation. The provider can be notified after immediate interventions have been made to stabilize the patient.

B. Insert an oral airway to prevent the client from biting the tube: Inserting an oral airway may be necessary if the client is biting the endotracheal tube, but this is unlikely the first action needed in response to a low-pressure alarm. If the client is not biting the tube, this action will not address the potential causes of the low-pressure alarm, such as a disconnection, leak, or circuit issue.

C. Suction the client and reset the alarm: While suctioning is an important intervention if secretions are the cause of ventilation issues, it is not the first action when the source of the low-pressure alarm is unclear. If a disconnection or leak is the issue, suctioning will not resolve the problem, and the nurse risks delaying appropriate action to address the source of the alarm. The priority is ensuring the client’s ventilation is not compromised, which is best accomplished by using a manual resuscitation bag until the problem is identified and corrected.

D. Disconnect the client from the ventilator and use a manual resuscitation bag: If the source of the low-pressure alarm cannot be identified after checking the client and the ventilator, the first priority is to ensure that the client continues to receive adequate ventilation. Disconnecting the client from the ventilator and using a manual resuscitation bag (Ambu bag) allows for immediate support of the patient's ventilation while the nurse investigates the cause of the alarm. This ensures the client's oxygenation and ventilation needs are met until the problem is resolved. It is critical to address any potential loss of positive pressure or leaks in the ventilator system promptly to avoid respiratory distress or failure.

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Arterial Blood Gases
pH	7.35-7.45
PaCO2	35-45mmHg
PaO2	80-100mmHg
HCO3-	22-26 mEq/L
O2 Saturation	>95%
Chemistry
BUN	8-21mg/dl
Creatinine	0.5-1.2mg/dl
Na	135-145 mEq/L
K	3.5-5.3 mEq/L
Cl	97-107 mEq/L
CO2	22-26 mEq/L
Ca	8.2-10.2 mg/dl
Glucose	65-99 mg/dl
Mg	1.7-2.2 mg/dl
PO4	2.5-4.5 mg/dl

The client diagnosed with multiple sclerosis (MS) is at risk for fatigue. Which priority intervention would the nurse implement to address this issue?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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