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. Tight shoes may indicate fluid retention in the lower extremities, which is a common symptom of right-sided heart failure. This condition leads to the backup of blood into the systemic circulation, causing peripheral edema.
B. Sleeping with two pillows may indicate left-sided heart failure, as the client may be experiencing orthopnea (difficulty breathing when lying flat).
C. Shortness of breath is more commonly associated with left-sided heart failure.
D. Waking up coughing every night is also a sign of left-sided heart failure, where pulmonary congestion leads to nocturnal coughing.
Correct Answer is C
Explanation
A. Pouring water over the genitals can help reduce the pain of urination, which is common in clients with genital herpes.
B. Washing hands carefully after applying ointment is important to prevent the spread of the virus.
C. The herpes simplex virus can be transmitted even when lesions are not present, so this statement indicates a need for further education. The virus can be spread through asymptomatic viral shedding.
D. Increasing fluid intake when lesions are open helps to prevent urinary retention and promote healing.
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