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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The primary concern in this scenario is urinary retention, which can lead to kidney dysfunction (indicated by elevated BUN and creatinine). The priority intervention is relieving the retention by inserting a Foley catheter, which will help restore normal urinary output and prevent further complications.
B. MRI is not an immediate priority when the client is at risk for kidney damage due to urinary retention.
C. While IV fluids may be necessary, the first priority is relieving the obstruction causing urinary retention.
D. Drawing blood is important for assessing the client's condition but is not as urgent as managing urinary retention.
Correct Answer is C
Explanation
A. Nuclear medicine scan is less commonly used for diagnosing gastric pain and dyspepsia.
B. Magnetic resonance imaging (MRI) is not the first choice for gastrointestinal issues.
C. Esophagogastroduodenoscopy (EGD) allows direct visualization of the upper GI tract, making it the most accurate diagnostic tool.
D. Abdominal arteriogram is typically used for vascular issues, not for diagnosing dyspepsia or gastric pain.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.