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. "My legs cramp when I walk more than a block." B. "I get short of breath when I climb a lot of stairs." C. "When I stand for too long, my feet start to swell." D. "My fingers hurt when I go outside in cold weather."

Correct Answer is A

Explanation

A. Intermittent claudication is characterized by cramping pain in the legs during physical activity, such as walking, due to insufficient blood flow, typically caused by peripheral arterial disease (PAD). This statement aligns with the symptoms of claudication.

B. Shortness of breath during physical exertion is more indicative of cardiovascular or pulmonary issues, not intermittent claudication.

C. Swelling in the feet from standing for extended periods is more consistent with venous insufficiency rather than intermittent claudication.

D. Pain in the fingers due to cold weather suggests Raynaud’s phenomenon, not intermittent claudication.

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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

While working in the outpatient clinic, the nurse notes that the client has a history of intermittent claudication. Which statement by the client would support this information?

Correct Answer is A

Explanation

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

A nurse leaves a coffee shop and sees a man lying on the ground. He is unresponsive and has no pulse and the nurse begins chest compressions. EMS arrives and connects the cardiac monitor displaying this rhythm. Identify the rhythm.

When evaluating the effectiveness of preoperative teaching with a client scheduled for coronary artery bypass graft (CABG) surgery using the internal mammary artery, the nurse determines that additional teaching is needed when the client says which of the following?

A client is being discharged home after a large myocardial infarction and subsequent coronary artery bypass grafting surgery. The client's sternal wound has not yet healed. What statement by the client most indicates a higher risk of developing sepsis after discharge?