What is the most important nursing intervention for a client with anemia and cerebral tissue hypoxia?

Correct Answer: A

Rationale: The correct answer is A: Providing rest periods throughout the day. This is the most important nursing intervention for a client with anemia and cerebral tissue hypoxia because rest helps reduce oxygen demand and allows for tissue oxygenation. Rest periods aid in preventing further tissue hypoxia, promoting healing, and improving overall well-being. Summary of other choices: B: Instituting energy conservation techniques - While conserving energy is important, rest is crucial for oxygenation in this scenario. C: Assisting in ambulation to the bathroom - Ambulation may be necessary, but rest takes precedence for oxygenation. D: Checking the temperature of water prior to bathing - Ensuring water temperature safety is important, but rest is essential for addressing cerebral tissue hypoxia.

Correct Answer: D

Rationale: The correct answer is D: Give 3 hyperinflations. Hyperventilating a patient before suctioning helps increase oxygen levels and reduce the risk of hypoxemia during the procedure. Hyperinflations involve delivering 3 deep breaths to the patient, which helps improve oxygenation and prepare the patient for suctioning. Choices A, B, and C are incorrect because simply giving inflations, adjusting oxygen flow rate, or providing 100% oxygen without hyperinflations may not adequately prepare the patient for suctioning and prevent hypoxemia.

Correct Answer: C

Rationale: The correct answer is C: Gag reflex. This is crucial to prevent aspiration during oral care for a comatose client. Checking the gag reflex helps ensure that the client can protect their airway and swallow safely. It is the top priority before providing any oral care to prevent potential choking or aspiration. The other choices are incorrect because: A: Presence of pain is important, but ensuring the client's safety and preventing aspiration takes precedence. B: Condition of the integumentary is not directly related to oral care and safety during the procedure. D: Joint mobility is also not directly related to oral care in a comatose client.

Correct Answer: B

Rationale: The correct answer is B: Check compatibility of the medication and IV fluids. Before administering the medications, it is crucial to ensure compatibility to prevent any adverse reactions or inactivation of the drugs. Checking compatibility involves verifying if the medications can be safely mixed and administered through the same IV line. This step helps in maintaining the effectiveness of the medications and ensuring patient safety. Summary: - Starting a second IV site (Choice A) is not necessary unless compatibility issues arise. - Mixing the prepackaged piperacillin/tazobactam per agency policy (Choice C) should only be done after verifying compatibility. - Priming the tubing with the IV solution and back-priming the medication (Choice D) should be done after confirming compatibility to avoid wastage.

Correct Answer: B

Rationale: Answer B is correct because performing chest physiotherapy one hour after meals helps prevent aspiration during the procedure. After meals, the risk of regurgitation and aspiration is higher, so waiting one hour allows for digestion and reduces these risks. Choices A, C, and D are incorrect because performing chest physiotherapy immediately before meals, during meals, or before bedtime can increase the risk of aspiration due to the timing in relation to eating.