Nokea
A client is concerned about extreme fatigue after an acute myocardial infarction. What is the best strategy the nurse can suggest to promote independence in self-care?
- A. Encourage the client to rest and let the healthcare team take over self-care tasks
- B. Instruct the client to gradually resume self-care tasks, with rest periods
- C. Assign assistive personnel to complete self-care tasks for the client
- D. Ask the client's family to assist with self-care
Correct Answer: B
Rationale: The best strategy to promote independence in self-care for a client concerned about extreme fatigue after an acute myocardial infarction is to instruct the client to gradually resume self-care tasks, with rest periods. This approach allows the client to regain independence without overexerting. Choice A is incorrect because encouraging the client to rest completely and letting the healthcare team take over self-care tasks may hinder independence. Choice C is incorrect as assigning assistive personnel to complete self-care tasks does not promote the client's independence. Choice D is not the best option as the primary focus should be on empowering the client to perform self-care tasks independently.
You may also like to solve these questions
A client at 30 weeks of gestation reports constipation. Which of the following recommendations should the nurse make?
- A. Drink 1 liter of water per day.
- B. Take a laxative every morning.
- C. Increase your intake of refined grains.
- D. Walk for at least 30 minutes every day.
Correct Answer: D
Rationale: The correct recommendation is to walk for at least 30 minutes every day. Walking stimulates intestinal motility, which can help relieve constipation during pregnancy. Option A is important for overall hydration but may not directly address constipation. Option B is not recommended without healthcare provider approval as some laxatives are contraindicated in pregnancy. Option C, increasing intake of refined grains, may exacerbate constipation due to lower fiber content.
What is an early sign indicating the need for suctioning a client's tracheostomy?
- A. Irritability
- B. Hypotension
- C. Flushing
- D. Bradycardia
Correct Answer: A
Rationale: Irritability is a crucial early sign that a client with a tracheostomy may require suctioning. Irritability could indicate a lack of oxygenation due to the airway blockage, prompting the need for suctioning to clear the airway. Hypotension, flushing, and bradycardia are not typically direct indicators for suctioning a tracheostomy. Hypotension may suggest hemodynamic instability, flushing could be related to autonomic responses, and bradycardia might indicate a cardiac issue rather than the need for suctioning.
What is an early sign that suctioning is needed for a client with a tracheostomy?
- A. Bradycardia
- B. Irritability
- C. Hypotension
- D. Decreased oxygen saturation
Correct Answer: B
Rationale: Irritability is an early sign that suctioning is needed for a client with a tracheostomy. When secretions accumulate in the airway, it can lead to discomfort and irritability in the client. Bradycardia, hypotension, and decreased oxygen saturation are usually later signs of inadequate airway clearance and oxygenation. Bradycardia may indicate severe hypoxia, while hypotension and decreased oxygen saturation are consequences of prolonged airway obstruction.
What are the key steps in administering oral medications to a patient with dysphagia?
- A. Crush medications and mix with food
- B. Use a straw to facilitate swallowing
- C. Encourage the patient to drink thickened liquids
- D. Have the patient lie flat during administration
Correct Answer: A
Rationale: The correct answer is A: Crush medications and mix with food. When administering oral medications to a patient with dysphagia, crushing the medications and mixing them with food is a common method to aid in swallowing. Choice B is incorrect because using a straw could pose a choking hazard for patients with dysphagia. Choice C is incorrect as thickened liquids may not always be suitable for all medications. Choice D is incorrect because having the patient lie flat can increase the risk of aspiration, which is not recommended for patients with dysphagia.
A nurse in a provider's office is collecting data from a preschooler. Which of the following findings should the nurse report to the provider?
- A. Heart rate 80/min
- B. Heart rate 90/min
- C. Respiratory rate 28/min
- D. Heart rate 146/min
Correct Answer: D
Rationale: A heart rate of 146/min is abnormal for a preschooler and indicates tachycardia, which should be reported to the provider. Choices A, B, and C fall within normal ranges for a preschooler's heart rate (80-120/min) and respiratory rate (22-34/min), so they do not require immediate reporting. Option D is the correct answer as it deviates significantly from the normal range and may indicate an underlying health issue that needs attention.