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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B. Heard over most of the lung fields, except for the major bronchi and the trachea.
Low intensity and pitch, with a longer inspiratory phase than expiratory phase. They are softer and more breezy in quality. Vesicular breath sounds are heard over the peripheral lung fields, including the apex (top) of the lungs.
A. Heard over the major bronchi, which are near the sternum and between the scapulae. They are of intermediate intensity and pitch, with equal inspiration and expiration phases. They are typically heard in the 1st and 2nd intercostal spaces along the sternal border and between the scapulae.
C. Heard over the trachea and larynx.
Characteristics: High intensity and pitch, with a short inspiratory phase and a longer expiratory phase. They are louder and harsher in quality, resembling the sound of air blowing through a hollow pipe.
D. Crackles are abnormal breath sounds that can be fine or coarse.
Fine crackles are high-pitched, short, popping sounds heard during inspiration, often due to fluid in the small airways or alveoli.
Coarse crackles are loud, low-pitched, bubbling sounds heard during inspiration, typically due to the presence of secretions in the larger airways.
Correct Answer is B
Explanation
B. This finding suggests deep tissue involvement and is characteristic of a Stage IV pressure injury. Stage IV pressure injuries involve full-thickness tissue loss with exposure of underlying structures such as bone, tendon, or muscle. This level of tissue damage requires extensive wound care and management to promote healing.
A. Thick dark eschar indicates necrotic tissue that typically covers the wound. While eschar itself is a characteristic of severe wounds, its presence alone does not define a Stage IV pressure injury. Eschar can be present in various stages of pressure injuries.
C. Partial-thickness loss of dermis typically corresponds to Stage II pressure injuries, where the injury extends into the epidermis and dermis but does not yet involve full-thickness tissue loss. This finding does not indicate a Stage IV pressure injury.
D. This finding is characteristic of a Stage III pressure injury, where the wound extends through the dermis into the subcutaneous tissue layer. In Stage IV pressure injuries, the damage progresses further to involve deeper structures such as muscle and bone, beyond the subcutaneous tissue.
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