A nurse is planning care for a client who is recovering from an acute myocardial infarction that occurred 3 days ago. Which of the following interventions should the nurse include?

Place the client in a supine position while resting.

Perform an ECG every 12 hours.

Draw a troponin level every 4 hours.

Obtain a cardiac rehabilitation consultation.

Answer and Explanation

The Correct Answer is D

Choice A reason: Supine positioning risks respiratory strain post-myocardial infarction; semi-Fowler’s is preferred. Cardiac rehabilitation is appropriate. Assuming supine is correct risks discomfort or complications, critical to avoid in ensuring proper positioning and recovery support for clients 3 days post-acute myocardial infarction.

Choice B reason: ECG every 12 hours is excessive 3 days post-myocardial infarction unless symptomatic; daily or as-needed is standard. Rehabilitation consultation is key. Assuming frequent ECGs risks unnecessary testing, critical to prevent in focusing on recovery planning and rehabilitation for post-infarction clients.

Choice C reason: Troponin levels every 4 hours are unnecessary 3 days post-myocardial infarction, as levels peak earlier; rehabilitation is priority. Assuming frequent troponin checks risks redundant testing, critical to avoid in ensuring appropriate care focus on recovery and rehabilitation post-acute myocardial infarction.

Choice D reason: Obtaining a cardiac rehabilitation consultation 3 days post-myocardial infarction supports recovery through structured exercise and education, critical for preventing further events. This intervention promotes long-term cardiac health, essential for reducing readmissions, enhancing recovery, and improving quality of life in post-infarction clients.

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Correct Answer is B

Explanation

Choice A reason: Protective eyewear is not required for MRI; removing transdermal patches prevents burns. Assuming eyewear is needed risks misinformation, potentially causing confusion, critical to avoid in ensuring accurate preparation and safety for clients undergoing MRI scans in diagnostic settings.

Choice B reason: Removing transdermal patches before an MRI prevents burns from metallic components, critical for client safety. This instruction ensures proper preparation, reducing injury risk, supporting safe imaging, and adhering to MRI safety protocols, essential for clients undergoing magnetic resonance imaging procedures.

Choice C reason: Tattoos are generally safe for MRI, though rare risks exist; patches are a greater concern. Assuming tattoos contraindicate MRI risks unnecessary restriction, potentially delaying diagnosis, critical to avoid in ensuring accurate preparation and access to imaging for clients with tattoos.

Choice D reason: Iodine allergy is relevant for CT contrast, not MRI, which uses gadolinium; patches are priority. Assuming iodine allergy contraindicates MRI risks misinformation, potentially delaying imaging, critical to prevent in ensuring proper preparation and safety for clients undergoing MRI scans.

A. Elevate the head of the client’s bed to 45°. B. Assess the client’s peripheral pulses every 15 minutes. C. Change the client’s dressing 4 hours following the procedure. D. Instruct the client to flex the right knee every 30 minutes.

Correct Answer is B

Explanation

Choice A reason: Elevating the bed to 45° increases bleeding risk at the femoral site post-catheterization; flat positioning is preferred. Assessing pulses is priority. Elevating risks hematoma, critical to avoid in ensuring vascular safety, monitoring for complications, and supporting recovery in immediate postoperative cardiac catheterization care.

Choice B reason: Assessing peripheral pulses every 15 minutes post-femoral catheterization monitors for arterial occlusion or bleeding, critical for detecting complications like hematoma or thrombosis. This ensures timely intervention, essential for vascular integrity, preventing limb ischemia, and supporting safe recovery in the immediate postoperative period.

Choice C reason: Changing the dressing 4 hours post-catheterization is premature unless soiled; initial monitoring of pulses is priority. Assuming dressing change is urgent risks disrupting the site, increasing bleeding, critical to avoid in ensuring site stability and vascular safety in immediate post-catheterization care.

Choice D reason: Flexing the right knee is contraindicated post-femoral catheterization, risking site disruption or bleeding; leg immobility is required. Assessing pulses is key. Instructing flexion risks hematoma, critical to prevent in ensuring vascular safety, monitoring complications, and supporting recovery in postoperative cardiac catheterization clients.

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A nurse is planning care for a client who is recovering from an acute myocardial infarction that occurred 3 days ago. Which of the following interventions should the nurse include?

Nursing Test Bank

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