A client is in the hospital after suffering a myocardial infarction and has bathroom privileges. The nurse assists the client to the bathroom and notes the client's O2 saturation to be 96%, pulse 88 beats/min, and respiratory rate 16 breaths/min after returning to bed. What action by the nurse is best?

Administer oxygen at 2 L/min.

Obtain a bedside commode.

Suggest the client use a bedpan.

Allow continued bathroom privileges.

Answer and Explanation

The Correct Answer is B

A. Administering oxygen is unnecessary at this time, as the client’s oxygen saturation is normal at 96%.

B. The client has had a myocardial infarction, which can lead to complications such as orthostatic hypotension or cardiovascular strain with sudden position changes. A bedside commode minimizes the need for the client to get out of bed and reduces the risk of these complications.

C. Suggesting the use of a bedpan may be an alternative but is less comfortable and may not adequately address the risk of strain from getting out of bed.

D. Allowing continued bathroom privileges may be unsafe, as it may increase the risk of a fall or cardiovascular strain.

Nursing Test Bank

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Correct Answer is B

Explanation

A. Lantus insulin does not directly affect potassium levels in the same way that digoxin does.

B. A potassium level of 3.0 mEq/L is low, and digoxin toxicity can occur when potassium levels are low, leading to an increased risk of arrhythmias. This requires immediate attention to avoid serious complications.

C. Metoprolol is a beta-blocker that does not directly cause hypokalemia and is less of an immediate concern.

D. Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that could affect kidney function but does not directly impact potassium levels as significantly as digoxin.

A. Place the client on bleeding precautions. B. Place the client in a private room. C. Document findings in the client's chart D. Collect blood cultures and start antibiotics.

Correct Answer is B

Explanation

A. Bleeding precautions are not required as the issue pertains to neutropenia, not thrombocytopenia.

B. Placing the client in a private room is appropriate as the ANC calculation (WBC × [% neutrophils]) indicates severe neutropenia, increasing the risk of infection.

C. Simply documenting findings does not address the client’s increased infection risk.

D. Blood cultures and antibiotics may be needed later but require additional signs of infection to proceed.

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Test Name	Results	Reference Range
WBC	12, 000	4, 000- 11, 000
Na+	149 mEq/L	135-145 mEq/L
K+	5.0 mEq/L	3.5- 5.0 mEq/L
Cl-	110 mEq/L	96-106 mEq/L
pH	7.34	7.35-7.45
PaCO2	34 mmHg	35- 45 mmHg
PaO2	78 mm Hg	80-100 mmHg
HCO3	21 mEq/L	22- 26 mEq/L

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Naxlex Comprehensive Predictor Exams

A client who has been receiving diuretic therapy is admitted to the emergency department with a serum potassium level of 3.0 mEq/L. The nurse should alert the health care provider immediately that the client is on which medication?

Correct Answer is B

Explanation

A client admitted to a medical - surgical unit has a CBC with differential drawn. Lab results show a WBC count of 4000, with neutrophil segments at 5% and neutrophil bands at 5%. Based on these values what would the nurse do? Calculate the absolute neutrophil count

Correct Answer is B

Explanation

Which assessment finding in a 36-year-old client is most indicative for further evaluation?

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