A nurse plans to ambulate a client on the third day after cardiac surgery. Which of the following interventions should the nurse take so that the client will best tolerate ambulation?

Provide the client with a walker.

Premedicate the client with the prescribed analgesic.

Obtain the client's vital signs and oximetry prior to ambulation.

Reinforce the client's surgical dressing.

Answer and Explanation

The Correct Answer is C

A. Provide the client with a walker: While a walker may be used during ambulation, ensuring the client's physiological readiness for ambulation takes precedence.

B. Premedicate the client with the prescribed analgesic: While pain management is important for comfort during ambulation, premedication may not be necessary for all clients and should be based on individual assessment.

C. Obtain the client's vital signs and oximetry prior to ambulation: This intervention allows the nurse to assess the client's physiological status and ensure stability before initiating ambulation, reducing the risk of complications.

D. Reinforce the client's surgical dressing: While maintaining the integrity of the surgical

incision is important, reinforcing the dressing alone does not ensure the client's readiness for ambulation.

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Correct Answer is A

Explanation

A. Troponin is a protein released into the bloodstream when there is damage to the heart muscle (myocardium), such as during a heart attack. Elevated troponin levels indicate myocardial injury or damage, making this the correct choice for indicating myocardial damage.

B. Erythrocyte sedimentation rate (ESR) measures the rate at which red blood cells settle in a tube of blood. It is a non-specific marker of inflammation and is not specific to myocardial damage.

C. Human B-type natriuretic peptide (BNP) is released by the heart in response to increased pressure and volume. Elevated levels are indicative of heart failure, not necessarily myocardial damage.

D. Activated partial thromboplastin time (aPTT) measures the time it takes for blood to clot. It is used to monitor the effectiveness of anticoagulant therapy and is not specific to myocardial

damage.

A. Take on an empty stomach. B. Take 1 hr before meals. C. Take 1 hr after meals. D. Take with meals.

Correct Answer is D

Explanation

A. Taking pancrelipase on an empty stomach may not provide optimal effectiveness as there would be no food in the stomach to mix with the enzymes for proper digestion.

B. Taking pancrelipase 1 hour before meals may not be as effective as taking it with meals because the enzymes need to be present when food enters the stomach for digestion.

C. Taking pancrelipase 1 hour after meals may not be as effective as taking it with meals because the enzymes need to be present when food enters the stomach for digestion.

D. Taking pancrelipase with meals is the correct instruction. Pancrelipase supplements the digestive enzymes that are deficient in individuals with cystic fibrosis, helping them digest food properly. Taking it with meals ensures that the enzymes are present when food enters the stomach, optimizing digestion and nutrient absorption.

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A nurse plans to ambulate a client on the third day after cardiac surgery. Which of the following interventions should the nurse take so that the client will best tolerate ambulation?

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