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
Stress and anxiety can contribute to gastrointestinal issues, but they are not the most likely cause of a duodenal ulcer.
Choice B rationale
Nonsteroidal anti-inflammatory drugs (NSAIDs) can cause gastrointestinal irritation and ulcers, but Helicobacter pylori infection is a more common cause.
Choice C rationale
Excessive alcohol consumption can irritate the stomach lining and contribute to ulcer formation, but Helicobacter pylori infection is more likely to be the primary cause.
Choice D rationale
Helicobacter pylori infection is the most common cause of duodenal ulcers. The bacteria damage the protective lining of the stomach and duodenum, leading to ulcer formation. .
Correct Answer is C
Explanation
Choice A rationale
Clamping the chest tube can cause increased pressure in the pleural space and is not appropriate without specific indications.
Choice B rationale
Increasing the wall suction may not relieve the burning sensation and could potentially cause harm.
Choice C rationale
Repositioning the client can help alleviate the burning sensation by adjusting the position of the chest tube and the lung.
Choice D rationale
Stripping the chest tube is not recommended as it can increase intrathoracic pressure and cause damage.
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