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 B
Explanation
Choice A rationale
A complete blood count (CBC) can provide information about the client's overall health and presence of infection, but it does not specifically address the potential underlying cause related to the urinary system.
Choice B rationale
Urinalysis with culture is the most relevant diagnostic test for evaluating the underlying cause of fever, chills, and severe left costovertebral pain. These symptoms suggest a possible urinary tract infection or pyelonephritis, which can be confirmed with urinalysis and culture.
Choice C rationale
A chest X-ray would not be the priority in this scenario as the symptoms suggest a urinary tract issue rather than a respiratory problem. A chest X-ray is more useful for assessing lung conditions.
Choice D rationale
A CT scan of the abdomen and pelvis can be helpful in evaluating the extent of a urinary tract infection or identifying other causes of abdominal pain, but it is typically not the first-line diagnostic test. Urinalysis with culture is more specific for identifying urinary infections. .
Correct Answer is C
Explanation
Choice A rationale
Intestinal malabsorption syndrome is not typically associated with ulcerative colitis or anemia caused by this condition. Malabsorption is more often related to other gastrointestinal conditions.
Choice B rationale
Intestinal parasites are not a common cause of anemia in individuals with ulcerative colitis. The chronic inflammation and blood loss are more likely contributors.
Choice C rationale
Chronic blood loss from the intestinal lining due to ulcerative colitis is a major contributing factor to anemia. The ongoing inflammation and ulceration can cause significant blood loss over time.
Choice D rationale
Dietary iron restrictions are not typically associated with ulcerative colitis. Anemia in this context is more likely due to chronic blood loss rather than dietary deficiencies.
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