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.

Answer and Explanation

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. .

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Correct Answer is C

Explanation

Choice A rationale

Encouraging the client to ambulate within 30 minutes following the procedure is not recommended as it could lead to complications such as bleeding or hematoma at the insertion site.

Choice B rationale

Keeping the client NPO for at least 2 hours following the procedure is not typically necessary and does not relate directly to the care required after a cardiac catheterization.

Choice C rationale

Assessing pulses in the client's affected arm is crucial to ensure that there is adequate blood flow and no compromise in circulation following the procedure.

Choice D rationale

Applying light pressure to the insertion site may help in preventing bleeding initially, but it is more critical to monitor for signs of bleeding or hematoma formation over time. .

A. Administer a laxative to cleanse the bowel before the CT scan. B. Administer the biguanide medication as scheduled. C. Advise the client to fast for 24 hours before the CT scan. D. Ensure the client is adequately hydrated before the CT scan.

Correct Answer is D

Explanation

Choice A rationale

Administering a laxative is not necessary for a CT scan of the abdomen with contrast. Laxatives are typically used for bowel preparation for procedures like colonoscopies.

Choice B rationale

Biguanide medications such as metformin should be held before and after the administration of contrast medium to prevent lactic acidosis, particularly in clients with liver disease.

Choice C rationale

Fasting for 24 hours is not required before a CT scan with contrast medium. Typically, clients are asked to fast for a few hours prior to the procedure.

Choice D rationale

Ensuring the client is adequately hydrated helps to protect kidney function and reduce the risk of contrast-induced nephropathy. Hydration is especially important for clients with a history of liver disease.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is evaluating a client who had a left-sided cardiac catheterization with an upper extremity insertion site.Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A client diagnosed with type II diabetes controlled with a biguanide medication and a history of liver disease is scheduled for a computed tomography (CT) scan with contrast medium of the abdomen to evaluate pancreatic function.Which intervention should the nurse implement?

Correct Answer is D

Explanation

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