A client with a recent ST segment elevation MI (STEMI) presents with bilateral lower extremity edema and crackles throughout the lung fields.What is the nurse's priority intervention for this client?
Increase the client's fluid intake to prevent dehydration.
Administer prescribed diuretics to reduce fluid overload.
Apply warm compresses to the lower extremities to reduce edema.
Encourage the client to ambulate to improve circulation.
The Correct Answer is B
Choice A rationale
Increasing fluid intake is contraindicated in clients with fluid overload, such as those with bilateral lower extremity edema and lung crackles. It can worsen the condition.
Choice B rationale
Administering prescribed diuretics is the priority intervention to reduce fluid overload in clients with heart failure post-STEMI. It helps to decrease edema and pulmonary congestion.
Choice C rationale
Applying warm compresses to the lower extremities may provide temporary relief but does not address the underlying issue of fluid overload.
Choice D rationale
Encouraging ambulation is beneficial for overall health but is not a priority intervention for managing fluid overload in this context. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
A complete blood count (CBC) can provide general information about the body's response to an MI, such as white blood cell count, but it is not definitive for diagnosing an MI.
Choice B rationale
A lipid profile measures cholesterol levels and helps assess cardiovascular risk, but it is not useful for diagnosing an acute MI.
Choice C rationale
An electrocardiogram (ECG) is essential for diagnosing an MI as it shows the heart's electrical activity and can indicate ischemia or infarction.
Choice D rationale
Troponin levels are the most specific and sensitive markers for myocardial infarction. Elevated troponin levels confirm heart muscle damage due to an MI, making it the definitive test.
Correct Answer is ["B","C","D"]
Explanation
Choice A rationale
Lying down after meals can increase the risk of acid reflux in individuals with a hiatal hernia. Patients are often advised to remain upright after eating to minimize symptoms.
Choice B rationale
Elevating the head of the bed helps prevent gastric contents from refluxing into the esophagus, reducing symptoms of hiatal hernia and promoting better sleep.
Choice C rationale
Reducing caffeine and spicy foods can help manage symptoms, as these substances can irritate the stomach lining and exacerbate reflux in hiatal hernia patients.
Choice D rationale
Maintaining a healthy weight is important because excess weight can increase abdominal pressure and contribute to the worsening of hiatal hernia symptoms.
Choice E rationale
Drinking less fluid is not typically a recommendation for hiatal hernia. Adequate hydration is important for overall health, and reducing fluid intake may not have a significant impact on symptoms.
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