The nurse is caring for a male patient, age 54, who had a myocardial infarction 2 days ago. His wife, who is very talkative, has remained at his bedside. Which of these interventions should the nurse implement to reduce the workload of the heart? (Select all that apply.)
Administer daily stool softener.
Provide bedside commode.
Advocate for rest periods with no visitors.
Provide regular diet.
Ambulate four times a day.
Maintain bedrest.
Correct Answer : A,B,C,F
Choice A reason: Administering a daily stool softener can help prevent straining during bowel movements, which can increase cardiac workload.
Choice B reason: Providing a bedside commode reduces the effort required to go to the bathroom, thus reducing cardiac workload.
Choice C reason: Advocating for rest periods with no visitors can help reduce emotional stress and physical exertion, which can increase cardiac workload.
Choice D reason: A regular diet is not specifically an intervention to reduce cardiac workload and may not be appropriate immediately following a myocardial infarction.
Choice E reason: Ambulating four times a day is not recommended immediately following a myocardial infarction as it can increase cardiac workload.
Choice F reason: Maintaining bedrest can help reduce the workload on the heart by minimizing physical activity.
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Related Questions
Correct Answer is C
Explanation
Choice A reason: Electroconvulsive therapy (ECT) requires informed consent, as it is a significant medical procedure involving anesthesia and induced seizures. Informed consent is a process where a patient is fully informed about the procedures and risks involved in a treatment and voluntarily agrees to it.
Choice B reason: Nurses cannot share information with a client's family without the client's permission due to confidentiality laws, except in specific circumstances defined by law. Patient information is protected under the Health Insurance Portability and Accountability Act (HIPAA), which requires patient consent for disclosure.
Choice C reason: Patients have the right to refuse medication. This right is part of the patient's autonomy and informed consent process. A mentally competent adult can refuse treatment, even if it may result in serious illness or death.
Choice D reason: The use of restraints in mental health facilities is highly regulated. Restraints may only be used when necessary to prevent immediate harm to the patient or others and must be discontinued as soon as the risk of harm has subsided.
Correct Answer is D
Explanation
Choice A reason: A high potassium level can increase the risk of digoxin toxicity. The normal range for potassium is typically 3.5 to 5.0 mEq/L, so a level of 5.5 mEq/L should be reported.
Choice B reason: A potassium level of 3.8 mEq/L is within the normal range and would not typically increase the risk of digoxin toxicity.
Choice C reason: A potassium level of 4.5 mEq/L is within the normal range and would not typically increase the risk of digoxin toxicity.
Choice D reason: A low potassium level can also increase the risk of digoxin toxicity, but the question asks for the result that does not increase the risk, making 2.9 mEq/L incorrect in this context.
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