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 C

Explanation

A) Cholesterol 200 mg/dL, HDL 50 mg/dL, triglycerides 140 mg/dL: While the total cholesterol level is at the borderline (200 mg/dL), the HDL level is within a reasonable range, and triglycerides are also normal. This set does not immediately indicate a need for dietary modifications.

B) Cholesterol 165 mg/dL, HDL 54 mg/dL, triglycerides 160 mg/dL: All values are within acceptable ranges. The total cholesterol is below 200 mg/dL, and the HDL and triglycerides are also in normal ranges, indicating that dietary modifications may not be necessary.

C) Cholesterol 200 mg/dL, HDL 35 mg/dL, triglycerides 190 mg/dL: The total cholesterol is at the upper limit, but the low HDL (35 mg/dL) is concerning, as it is below the desirable level of 40 mg/dL. Low HDL is associated with increased cardiovascular risk, indicating a strong need for dietary modifications to improve heart health.

D) Cholesterol 180 mg/dL, HDL 40 mg/dL, triglycerides 220 mg/dL: While the total cholesterol is within a normal range, the triglycerides are elevated (above 150 mg/dL), which indicates a risk factor for coronary artery disease. Dietary modifications may be warranted, but the HDL is at the lower end of normal.

A. Have biannual renal function studies B. Stop the medication if you develop a headache C. Report muscle weakness or pain D. Monitor body weight weekly

Correct Answer is C

Explanation

A. Have biannual renal function studies: While monitoring renal function can be important, it is not specifically required for all patients on rosuvastatin. The focus should be on liver function and muscle-related side effects.

B. Stop the medication if you develop a headache: Headaches are not a common or serious side effect of rosuvastatin. Patients should not stop the medication without consulting their healthcare provider unless they experience severe symptoms.

C. Report muscle weakness or pain: This is critical information to provide. Statins, including rosuvastatin, can cause muscle-related side effects such as myopathy or rhabdomyolysis. Patients should be instructed to report any unexplained muscle weakness, pain, or tenderness.

D. Monitor body weight weekly: While maintaining a healthy weight is important, weekly weight monitoring is not a standard recommendation for patients taking rosuvastatin.

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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

The nurse is reviewing the laboratory data of a client diagnosed with coronary artery disease. Which set of laboratory results indicates a need for client teaching regarding dietary modifications?

Correct Answer is C

Explanation

The client is prescribed rosuvastatin 10 mg PO daily. What information will the nurse provide in the teaching about this medication?

Correct Answer is C

Explanation

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