A client with a recent ST segment elevation MI (STEMI) presents with bilateral lower extremity edema and crackles throughout the lung fields.What is the nurse's priority intervention for this client?
Increase the client's fluid intake to prevent dehydration.
Administer prescribed diuretics to reduce fluid overload.
Apply warm compresses to the lower extremities to reduce edema.
Encourage the client to ambulate to improve circulation.
The Correct Answer is B
Choice A rationale
Increasing fluid intake is contraindicated in clients with fluid overload, such as those with bilateral lower extremity edema and lung crackles. It can worsen the condition.
Choice B rationale
Administering prescribed diuretics is the priority intervention to reduce fluid overload in clients with heart failure post-STEMI. It helps to decrease edema and pulmonary congestion.
Choice C rationale
Applying warm compresses to the lower extremities may provide temporary relief but does not address the underlying issue of fluid overload.
Choice D rationale
Encouraging ambulation is beneficial for overall health but is not a priority intervention for managing fluid overload in this context. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Alcoholism is a common cause of hypomagnesemia due to poor dietary intake, increased renal excretion, and gastrointestinal losses. Chronic alcohol consumption leads to malnutrition and loss of magnesium through the urine, contributing to low magnesium levels.
Choice B rationale
Dehydration typically leads to hemoconcentration, which can elevate, rather than decrease, magnesium levels. Thus, it is not usually associated with low magnesium levels.
Choice C rationale
Kidney failure generally causes hypermagnesemia, not hypomagnesemia, because the kidneys cannot efficiently excrete magnesium, leading to its accumulation in the blood.
Choice D rationale
Excessive magnesium intake would result in hypermagnesemia, not hypomagnesemia, as the body accumulates more magnesium than it can excrete.
Correct Answer is C
Explanation
Choice A rationale
Administering post-procedure antibiotics is not typically required for a bronchoscopy unless there is evidence of infection. The procedure itself does not inherently pose a high risk of infection requiring antibiotics as a preventative measure.
Choice B rationale
Providing pre-procedure sedation is important to ensure the client is comfortable and relaxed during the bronchoscopy. This helps minimize discomfort and anxiety associated with the procedure.
Choice C rationale
Ensuring the client is NPO (nothing by mouth) for a specific period before the procedure is crucial to prevent aspiration. Aspiration can occur if the client has food or liquid in their stomach, posing a serious risk during the insertion of the bronchoscope.
Choice D rationale
Encouraging the client to drink plenty of fluids before the procedure is not appropriate because the client needs to be NPO to prevent aspiration risks during the bronchoscopy.
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