A client with coronary artery disease is hospitalized with unstable angina. To reduce cardiac workload, which intervention should the nurse include in the client's plan of care?

Encourage active range of motion exercises.

Assist with ambulation in the hallway.

Provide a bedside commode for toileting.

Teach to sleep in a side lying position.

Answer and Explanation

The Correct Answer is C

A.   Range of motion exercises are important for overall mobility and prevention of complications from immobility. However, they can increase cardiac workload, especially if performed actively and without supervision.
B.   Ambulation, or walking in the hallway, increases cardiac workload and can exacerbate symptoms in a client with unstable angina. This activity should be minimized or restricted until the client's condition stabilizes. The focus should be on reducing activities that put additional stress on the heart.

C.   Using a bedside commode helps reduce the need for the client to walk to the bathroom, which can be physically demanding and increase cardiac workload. By minimizing the effort required for toileting, the client can avoid unnecessary physical strain.
D.   Sleeping in a side-lying position is not directly related to reducing cardiac workload. The client's position during sleep generally does not have as significant an impact on cardiac workload as other interventions.

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Correct Answer is A

Explanation

A. This directly indicates that the lithotripsy procedure was successful in breaking down the stone into smaller fragments that can be passed through the urinary tract.
B. While the absence of these symptoms is a positive sign, it does not directly confirm the success of the lithotripsy procedure. These symptoms can be present even if the stone has been broken down.
C. Pale pink urine is expected after lithotripsy due to minor bleeding. The absence of blood clots is also a good sign, but it doesn't definitively confirm the procedure's success.
D. Serum creatinine and blood urea nitrogen (BUN) levels are within normal limits. These lab values are important indicators of kidney function but do not directly relate to the success of the lithotripsy procedure itself.

A. Schedule a portable chest x-ray per PRN protocol. B. Maintain the current IV antibiotic schedule. C. Obtain a specimen of the drainage for culture. D. "Milk" the tube to remove any clots.

Correct Answer is C

Explanation

A. A chest x-ray can be useful to assess for complications or changes in lung status, such as pneumothorax, pleural effusion, or changes in lung volume. However, the change in drainage color from viscous green to clear watery fluid may not immediately warrant an x-ray unless there are additional clinical concerns or symptoms suggesting a need for imaging.
B. Continuing the IV antibiotic schedule is important if there is an ongoing infection that needs treatment. However, if the change in drainage is significant and suggests a potential change in the underlying condition or complication, it’s important to evaluate the cause of the change rather than solely relying on antibiotics.
C. Obtaining a specimen of the drainage for culture is a valuable action if there is concern about infection or if the drainage characteristics have changed unexpectedly. Clear, watery fluid could indicate the presence of serous fluid or a change in the nature of the drainage, potentially due to infection or resolution of an infection.
D. “Milking” or stripping the chest tube is not recommended as a routine practice because it can create negative pressure and potentially damage the pleural tissues or exacerbate issues. Additionally, the change in the drainage from viscous green to clear watery fluid does not necessarily indicate that clots are present or that tube milking would be helpful.

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A client with coronary artery disease is hospitalized with unstable angina. To reduce cardiac workload, which intervention should the nurse include in the client's plan of care?

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Naxlex Comprehensive Predictor Exams

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