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)

Allow for rest periods between activities throughout the day

Provide supplemental oxygen when the pulse oximetry falls below 96%

Perform serial neurologic assessments to maintain safety and prevent injury

Assess ability to perform activities of daily living (ADLS)

Monitor blood pressure, pulse and respirations after activity

Answer and Explanation

Correct Answer : A,B,C,D,E

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.

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Correct Answer is A

Explanation

A) Maintain IV fluid infusion and assess adequacy of hydration: This is the best nursing action as adequate hydration is crucial in managing sickle cell crisis. It helps to reduce blood viscosity and prevent further sickling of red blood cells, which is especially important in the context of pneumonia, as dehydration can exacerbate the crisis.

B) Provide continuous sedation for pain relief: While managing pain is essential, continuous sedation is not the most appropriate first step in this situation. Pain management should be addressed, but hydration and treating the underlying causes (like pneumonia) take priority.

C) Insert an indwelling (Foley) catheter and monitor hourly urinary output: While monitoring urinary output can be important, it is not the most immediate action in this case. Focus should be on hydration and addressing the sickle cell crisis rather than on urinary output at this time.

D) Prepare for endotracheal intubation and ventilatory support: Although respiratory distress is a concern with pneumonia, the current pulse oximetry reading of 96% indicates adequate oxygenation at this time. Preparing for intubation should not be the first action unless the patient shows signs of respiratory failure or severe distress.

A. should continue to read the labels of foods I select in the grocery store." B. When get out of bed in the morning. I should first sit for a few minutes and then stand." C. will be able to stop my anti-hypertensive medication when my blood pressure is normal." D. "Keeping my blood pressure under control reduces my risk for a heart attack."

Correct Answer is C

Explanation

A. "I should continue to read the labels of foods I select in the grocery store.": This statement is appropriate as reading labels helps the client avoid high sodium and unhealthy fats, which can negatively impact blood pressure.

B. "When I get out of bed in the morning, I should first sit for a few minutes and then stand.": This statement reflects a good understanding of managing potential orthostatic hypotension, which can occur with antihypertensive medications. It indicates awareness of the need to rise slowly to prevent dizziness.

C. "I will be able to stop my anti-hypertensive medication when my blood pressure is normal.": This statement indicates a need for clarification. Many patients believe that once their blood pressure is normal, they can discontinue medication, but hypertension is often a chronic condition that requires ongoing management to maintain blood pressure control.

D. "Keeping my blood pressure under control reduces my risk for a heart attack.": This statement is accurate and demonstrates an understanding of the importance of hypertension management in reducing cardiovascular risk.

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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)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is experiencing sickle cell crisis precipitated by a right lower lobe pneumonia. The vital signs are: HR-110/min: RR-28; B/P-96/54: T-100.8 PO: Pulse Oximetry-96%. What is the best nursing action?

Correct Answer is A

Explanation

Which statement, made by a client receiving pharmacologic therapy for hypertension, indicates a need for further clarification by the nurse?

Correct Answer is C

Explanation

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The nurse caring for the client diagnosed with sickle cell crisis places priority on which specific goal(s) prior to discharge? (SELECT ALL THAT APPLY)

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