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

Answer and Explanation

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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Correct Answer is D

Explanation

D. This problem indicates that the client is not receiving adequate nutrition to meet metabolic needs, which can lead to malnutrition and compromised healing. Addressing imbalanced nutrition is crucial for maintaining health and supporting recovery.

A. This problem refers to disturbances in sexual function or satisfaction. While important to address, it is not typically considered a high priority compared to other physiological or safety-related issues unless it B This problem indicates the potential for the client to experience loneliness or social disconnection, which can impact mental and emotional well-being. While addressing social isolation is important for holistic care, it may not be as urgent as issues related to physical health or safety.

C This problem indicates the inability to endure physical activities or exercise due to insufficient physiological or psychological energy. Activity intolerance can be a significant concern post-operatively or in clients with chronic conditions, as it can affect recovery and overall functional ability.

A. ibuprofen liquid 300 mg Q 6 hours prn for pain B. potassium chloride XL 40 mEq daily C. levothyroxine 25 mcg daily D. multivitamin liquid 10 mL daily

Correct Answer is B

Explanation

B.This formulation is not intended for administration through a gastrostomy tube and could be harmful to the patient. It is essential to consult with a pharmacist or physician to find a suitable alternative that is safe for administration through the gastrostomy tube

A. Ibuprofen is typically administered orally (PO) and is absorbed in the gastrointestinal tract.

C. Levothyroxine is a thyroid hormone replacement medication crucial for maintaining thyroid hormone levels in individuals with hypothyroidism. It is typically administered orally in the morning on an empty stomach to ensure optimal absorption.

D. Liquid formulations are suitable for administration through gastrostomy tubes, as they are generally well-tolerated and absorbed.

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The nurse is providing for the hygiene needs of a client with an activity intolerance. Which is the priority nursing intervention?

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