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 B

Explanation

A) Pedal pulses are +1 bilaterally: While this may indicate decreased perfusion, it is not an immediate concern that typically requires reporting before a cardiac angiogram. This finding should be monitored but does not usually contraindicate the procedure.

B) Client has multiple food allergies: This information is critical to report prior to the procedure, especially if any of the allergies pertain to medications or contrast agents used during the angiogram. Knowing about allergies can help prevent potential allergic reactions during the procedure.

C) Admission blood pressure is 110/70: This blood pressure reading is within an acceptable range for most patients. While the healthcare provider should be aware of baseline vitals, this alone does not necessitate immediate reporting.

D) Client is slightly anxious: While anxiety is important to acknowledge and may require intervention, it is common for clients undergoing procedures. This does not typically need to be reported urgently to the healthcare provider prior to the angiogram.

A. restrain the client to prevent self-harm B. assist the client to identify the trigger situation and choose a coping strategy. C. send the client to the crisis intervention unit for 23 hours of observation. D. advise the client to take an anxiolytic to decrease their anxiety level.

Correct Answer is B

Explanation

A. Restraining the client to prevent self-harm: While safety is a priority, physical restraint should be a last resort and not the first action taken in this scenario. It may escalate the situation and lead to feelings of loss of control.
B. Assist the client to identify the trigger situation and choose a coping strategy: This is the best initial intervention. Helping the client understand their triggers and encouraging the development of coping strategies can empower them and promote healthier responses to distress. This approach aligns with therapeutic practices that support emotional regulation.

C. Send the client to the crisis intervention unit for 23 hours of observation: While observation may be necessary if the client is at imminent risk of self-harm, it is essential first to explore the underlying issues and coping mechanisms. This action may be considered if the client remains a danger to themselves after initial interventions.

D. Advise the client to take an anxiolytic to decrease their anxiety level: Medications may help with anxiety, but this approach does not address the root of the problem or provide the client with skills to manage their distress. It is more beneficial to focus on therapeutic techniques first.

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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

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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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