A client is in the hospital after suffering a myocardial infarction and has bathroom privileges. The nurse assists the client to the bathroom and notes the client's O2 saturation to be 96%, pulse 88 beats/min, and respiratory rate 16 breaths/min after returning to bed. What action by the nurse is best?

Administer oxygen at 2 L/min.

Obtain a bedside commode.

Suggest the client use a bedpan.

Allow continued bathroom privileges.

Answer and Explanation

The Correct Answer is B

A. Administering oxygen is unnecessary at this time, as the client’s oxygen saturation is normal at 96%.

B. The client has had a myocardial infarction, which can lead to complications such as orthostatic hypotension or cardiovascular strain with sudden position changes. A bedside commode minimizes the need for the client to get out of bed and reduces the risk of these complications.

C. Suggesting the use of a bedpan may be an alternative but is less comfortable and may not adequately address the risk of strain from getting out of bed.

D. Allowing continued bathroom privileges may be unsafe, as it may increase the risk of a fall or cardiovascular strain.

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Correct Answer is A

Explanation

A. Cleaning the skin and clipping hairs ensures good electrode contact, which is essential for accurate ECG readings. This is the correct statement.

B. Oxygen should not be turned off unless specifically instructed by a provider. It does not interfere with ECG monitoring.

C. Electrodes should be placed on the anterior chest for standard ECG monitoring, not on the posterior chest.

D. Electrodes for ECG monitoring typically come with adhesive backing and do not require additional gel.

A. Administer multiple vitamins and minerals in the IV solution. B. Infuse total parenteral nutrition via a central catheter. C. Encourage an oral intake of at least 3000 kcal per day. D. Insert a feeding tube and initiate enteral feedings.

Correct Answer is D

Explanation

A. Administering multiple vitamins and minerals via IV alone would not be sufficient for adequate nutrition in this patient, especially given the large burn surface area.

B. Total parenteral nutrition (TPN) may be used if enteral feeding is not possible, but enteral feeding is usually preferred when feasible.

C. Encouraging oral intake is not appropriate for a client with a 60% TBSA burn, as they would likely require more significant nutritional support than oral intake can provide.

D. Enteral feeding is the preferred method for nutrition in burn patients as it maintains gut integrity and prevents the complications associated with parenteral nutrition. Although the client has absent bowel sounds and a distended abdomen, this can be common early in burn care, and enteral feedings should be started as soon as feasible to prevent malnutrition and promote recovery.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse supervises an assistive personnel (AP) applying electrocardiographic monitoring. Which statement would the nurse provide to the AP related to this procedure?

Correct Answer is A

Explanation

A client has just been admitted with a 60% total body surface area (TBSA) burn injury. The nurse notes a distended abdomen with absent bowel sounds in all quadrants. To maintain adequate nutrition, the nurse should plan to take which action?

Correct Answer is D

Explanation

A nurse reviews a client's laboratory results. Which findings would alert the nurse to the possibility of atherosclerosis? (Select all that apply.)

An emergency department nurse triages clients who present with chest discomfort. Which client would the nurse plan to assess first?

A client with extensive electrical burn injuries is admitted to the emergency department. Which prescribed intervention should the nurse implement first?

The nurse is providing preoperative education to a client prior to having an orchiectomy for testicular cancer. What statement by the client indicates the need to review the information?

After receiving change-of-shift report, which client should the nurse assess first?

A client with chronic obstructive pulmonary disease (COPD) has poor gas exchange. Which action by the nurse would support the client's ventilation?