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. This statement indicates that the client may not fully understand the care required for the drainage tubes. Drainage tubes typically do not "fall out" on their own; they need to be removed by a healthcare provider. The client should be instructed to care for the tubes, monitor drainage, and report any concerns to their healthcare provider.

B. It is appropriate to measure the drainage each day and report it if it exceeds the expected amount. This helps ensure that the surgical site is healing properly.

C. The client should be cautious with the positioning of the drainage tubes to avoid kinking or pulling, which could interfere with drainage and cause complications.

D. A foul odor from the drainage could indicate an infection, so it is appropriate for the client to contact their primary healthcare provider if this occurs.

A. "This condition is caused by the coronary arteries spasming, not by cholesterol." B. "Just because you're young and eat right doesn't mean you can't have plaque buildup." C. "I understand it can be upsetting to have coronary artery disease at your age." D. "I am sure everything will be alright."

Correct Answer is A

Explanation

A. The best response is to educate the client about the cause of Prinzmetal angina. It occurs due to spasm in the coronary arteries, which is different from the plaque buildup seen in traditional coronary artery disease. This response addresses the client's concern in an accurate and reassuring manner.

B. While healthy eating is important, Prinzmetal angina is not typically caused by cholesterol or plaque buildup. This response could increase the client's anxiety.

C. While acknowledging the client's emotions is important, this response does not address the underlying concern or provide an accurate explanation of Prinzmetal angina.

D. Offering reassurance without providing accurate information about the condition does not help the client understand the cause of their symptoms and could leave them confused or anxious.

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Naxlex Comprehensive Predictor Exams

A client is discharged to home after a modified radical mastectomy with two drainage tubes. Which statement by the client would indicate that further teaching is needed?

Correct Answer is A

Explanation

Correct Answer is A

Explanation

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