The nurse is providing for the hygiene needs of a client with an activity intolerance. Which is the priority nursing intervention?
Administering oxygen during provision of care
Assessing response to activity
Providing rest periods every ten minutes
Maintaining the bed in high-Fowler's position
The Correct Answer is B
B. Before, during, and after providing hygiene care, the nurse should continually assess the client's response to activity. Signs such as increased heart rate, shortness of breath, fatigue, or discomfort should be monitored closely. Assessing the client's response allows the nurse to adjust care activities as needed to prevent exacerbation of symptoms or complications.
A. Administering oxygen may be necessary if the client has respiratory compromise or if oxygen saturation levels are low during activities. However, this intervention should be based on the client's specific needs as assessed by the nurse and should not necessarily be a routine intervention
C Providing regular rest periods is an important intervention for clients with activity intolerance. However, the assessment will guide how and when these interventions should be implemented.
D. Fowler's position are also important, but the assessment will guide how and when these interventions should be implemented.
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Related Questions
Correct Answer is D
Explanation
D. When clients perceive that the knowledge or information being presented is beneficial to their health outcomes, they are more likely to be motivated to learn. Understanding how the knowledge can improve their health, manage their condition, or prevent complications provides intrinsic motivation to engage in learning activities.
A. While health literacy is important for understanding health information, having a high level of health literacy alone does not guarantee motivation to learn. Motivation to learn is more about personal engagement and perceived relevance of the information to one's own health and well-being.
B. While this may provide motivation for compliance with treatment plans or learning specific self-care tasks required for discharge, it does not necessarily translate to a strong motivation to learn beyond immediate needs related to discharge.
C. Formal education may contribute to overall cognitive abilities and learning skills, but it does not automatically translate into motivation to learn in a healthcare context. Motivation to learn is more about personal interest, perceived relevance, and understanding the benefits of acquiring new knowledge.
Correct Answer is A
Explanation
A. This principle emphasizes the duty to do no harm. In the case of the client undergoing chemotherapy and experiencing severe side effects that significantly reduce their quality of life, the principle of nonmaleficence comes into question. Chemotherapy, while aimed at treating cancer, often causes substantial side effects that can impact a patient's well-being
BThis principle relates to fairness and equality in the distribution of resources, treatments, and outcomes. In the context of cancer treatment, justice could be considered in terms of ensuring equitable access to chemotherapy and supportive care, regardless of socioeconomic status or other factors.
C Fidelity refers to the duty to be faithful, keep promises, and maintain trust in the patient-nurse relationship. In this context, fidelity would involve the nurse advocating for the client's best interests, including addressing their concerns about the severe side effects of chemotherapy and their impact on quality of life.
D. Autonomy refers to respecting the right of the patient to make their own decisions about their care and treatment. In the context of cancer treatment, autonomy would involve ensuring that the client has sufficient information about their condition, prognosis, treatment options, and potential side effects to make informed decisions. However, autonomy may also be challenged when severe side effects significantly impact the client's ability to maintain their desired quality of life despite ongoing treatment.
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