The client problem of Activity Intolerance related to decrease in cardiac reserve is identified for a client with chronic heart failure. Which intervention should the nurse include in the plan of care related to this problem?
Teach family members to assist with all ADLS once discharged
Cluster activities to a time when the client has the most energy
Provide alternating activity and rest periods
Limit self-care activities until symptoms subside
The Correct Answer is C
A. While family support is important, encouraging complete assistance with all activities of daily living (ADLs) is not an ideal intervention. The goal is to maintain as much independence as possible, even if that means modifying or pacing activities. Encouraging complete dependency can lead to deconditioning and further loss of function.
B. Clustering activities is not the best intervention for this problem. Clustering involves grouping multiple tasks together at once, which can overwhelm the patient and lead to fatigue. Instead, the nurse should encourage pacing and spreading out activities to avoid overexertion, even if the patient has energy.
C. Providing alternating periods of activity and rest is a fundamental strategy in managing activity intolerance due to chronic heart failure. This approach helps balance the energy demands of daily activities with rest to prevent fatigue and overexertion. By alternating activity and rest, the patient can perform necessary tasks while minimizing strain on the heart.
D. The goal in chronic heart failure is to help the patient maintain independence and function as much as possible. Limiting self-care could lead to increased dependency and reduced quality of life. Activity modifications and appropriate pacing are better strategies.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
A. Increased respiratory rate - Fluid overload can lead to pulmonary edema, which causes difficulty breathing and an increased respiratory rate.
B. Increased temperature - Fluid overload does not typically cause a temperature increase. A fever may indicate infection rather than fluid overload.
C. Increased heart rate - The body compensates for fluid overload by increasing the heart rate to maintain cardiac output.
D. Increased blood pressure - Fluid overload leads to increased blood volume, which results in elevated blood pressure.
E. Increase hematocrit - Hematocrit usually decreases with fluid overload, as it is diluted by the extra fluid volume.
Correct Answer is ["5"]
Explanation
(desired dose in mg/hr) / (concentration of medication in mg/mL) = infusion rate in mL/hr.
In this case, the desired dose is 5 mg/hr, and the concentration of medication is 125 mg in 125 mL, which simplifies to 1 mg/mL.
Therefore, the infusion rate is 5 mg/hr divided by 1 mg/mL, resulting in an infusion rate of 5 mL/hr.
Rounding to the nearest whole number, the nurse should set the IV pump to 5 mL/hr.
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