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 C
Explanation
A. Mild hyponatremia (Sodium < 135 mEq/L) typically does not produce distinctive ECG changes. This value is unlikely to correlate with the presence of U waves.
B. Hyperkalemia (Potassium > 5.0 mEq/L) is associated with peaked T waves, widened QRS complexes, and flattened or absent P waves, not U waves.
C. Hypokalemia (Potassium < 3.5 mEq/L) is the primary cause of U waves. A potassium level of 2.1 mEq/L is significantly low and can result in ECG changes, including U waves, ST segment depression, and prolonged QT intervals. These changes reflect altered ventricular repolarization.
D. Hypermagnesemia (Magnesium > 2.5 mEq/L) can cause ECG changes such as prolonged PR and QRS intervals, bradycardia, and heart block. However, such an extreme magnesium level of 18 mEq/L would cause severe toxicity and is not associated with U waves.
Correct Answer is B
Explanation
A. Drinking water in hot weather is important to prevent dehydration. This is not a risk factor for metabolic alkalosis unless the client is excessively losing electrolytes through sweating and not replacing them.
B. Sodium bicarbonate is an alkaline substance, and regular use, especially after meals, can contribute to metabolic alkalosis. The client should be instructed on the potential risks of using sodium bicarbonate too frequently.
C. Avoiding milk due to gastrointestinal symptoms does not directly contribute to metabolic alkalosis.
D. Digoxin does not directly affect acid-base balance, but it requires monitoring due to potential interactions with other medications or electrolyte imbalances.
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