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.

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Correct Answer is A

Explanation

A. Cleaning the skin and clipping hairs ensures good electrode contact, which is essential for accurate ECG readings. This is the correct statement.

B. Oxygen should not be turned off unless specifically instructed by a provider. It does not interfere with ECG monitoring.

C. Electrodes should be placed on the anterior chest for standard ECG monitoring, not on the posterior chest.

D. Electrodes for ECG monitoring typically come with adhesive backing and do not require additional gel.

A. Test the equipment by delivering a smaller shock at 50 J. B. Administer 2 mg of intravenous epinephrine. C. Make sure that the defibrillator is set to the synchronous mode. D. Ensure that everyone is clear of contact with the client and the bed.

Correct Answer is D

Explanation

A. Testing the equipment with a smaller shock is unnecessary when preparing to defibrillate in an emergency.

B. Epinephrine is used in cases of cardiac arrest with no pulse, particularly in asystole or pulseless electrical activity (PEA), not immediately before defibrillation in ventricular fibrillation.

C. Synchronous mode is used for cardioversion, not for defibrillation. Defibrillation should be delivered in unsynchronized mode.

D. Before delivering a shock, it is essential to ensure that everyone, including the nurse, is clear of the client and any conductive surfaces like the bed. This prevents injury from the electrical shock.

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Naxlex Comprehensive Predictor Exams

A nurse supervises an assistive personnel (AP) applying electrocardiographic monitoring. Which statement would the nurse provide to the AP related to this procedure?

Correct Answer is A

Explanation

A nurse prepares to defibrillate a client who is in ventricular fibrillation. Which intervention is appropriate for the nurse to perform prior to defibrillating this client?

Correct Answer is D

Explanation

The healthcare provider orders dobutamine at 12 mcg/kg/min. The client weighs 75 kg. The pharmacy provides 250 mL of D5W with 1 g of dobutamine. How many mL/hr should the IV pump be programmed for? (Round to a whole number.)

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