The nurse is caring for a client recovering from a recent myocardial infarction. To reduce cardiac workload, which intervention should the nurse include in the client's plan of care?
Assist with ambulation in the hallway.
Provide a bedside commode for toileting.
Encourage active range of motion exercise.
Teach to sleep in a side-lying position.
The Correct Answer is B
A. Assist with ambulation in the hallway: While progressive ambulation is part of cardiac rehabilitation, early ambulation too soon after a myocardial infarction may increase myocardial oxygen demand and cardiac workload.
B. Provide a bedside commode for toileting: Using a bedside commode reduces the effort and energy expenditure required to walk to the bathroom, thus lowering cardiac workload. This helps prevent unnecessary increases in heart rate and oxygen demand.
C. Encourage active range of motion exercise: Active range of motion is beneficial for preventing complications like thromboembolism, but if done too aggressively or frequently early post-MI, it can stress the heart.
D. Teach to sleep in a side-lying position: Sleeping position may affect comfort and breathing but does not significantly influence cardiac workload. Semi-Fowler’s position may be more beneficial in reducing preload in cardiac patients than simply lying on the side.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Begin chest compressions at a depth of at least 2 in (5.1 cm): Initiating high-quality chest compressions immediately is the priority in a pulseless and non-breathing client. This promotes circulation of oxygenated blood to vital organs, and improves chances of survival until defibrillation or advanced care is available.
B. Perform forceful sternal rub to check for unresponsiveness: A sternal rub is used to assess responsiveness, but it is unnecessary once the client is confirmed to be unresponsive, pulseless, and not breathing. Delaying compressions could reduce survival chances.
C. Assess the client for any obvious injuries due to the sudden fall: While it is important to note injuries, it is not the immediate priority in a client without a pulse or respirations. Life-saving measures such as CPR should take precedence over secondary assessments.
D. Remove the client's clothes and apply automated external defibrillator (AED) pads to chest: Applying the AED is a critical step but should follow the immediate initiation of chest compressions. If another responder is present, tasks can be divided, but CPR should not be delayed for AED pad placement.
Correct Answer is A
Explanation
A. Continue to monitor the client's condition: The ABG values are all within normal limits: pH 7.38, PaCO₂ 40 mm Hg, HCO₃⁻ 24 mEq/L, and PaO₂ 90 mm Hg. This indicates adequate acid-base balance and oxygenation. No immediate intervention is needed, so continued monitoring is the most appropriate nursing action.
B. Encourage the client to cough and deep breathe: Coughing and deep breathing are useful for clearing secretions or improving oxygenation in clients with hypoxia or atelectasis. However, the client’s PaO₂ is within the normal range, so this intervention is unnecessary.
C. Administer oxygen per face mask per PRN protocol: Supplemental oxygen is used when PaO₂ levels are below normal or when signs of respiratory distress are present. Since the client’s PaO₂ is 90 mm Hg, which is normal, there is no need to initiate oxygen therapy.
D. Instruct the client to breathe into a paper bag: Breathing into a paper bag is used to treat hyperventilation leading to respiratory alkalosis. The client’s ABG results do not show alkalosis; therefore, this intervention would be inappropriate and potentially harmful.
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