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 D
Explanation
Choice D rationale
Ensuring a clear airway is the priority intervention in cases of diabetic ketoacidosis with hypoxia. Hypoxia refers to a deficiency in the amount of oxygen reaching tissues. Without a clear airway, oxygen cannot be effectively delivered to the lungs, and subsequently to the bloodstream and tissues. Addressing the client's airway ensures that oxygenation can be improved promptly, which is critical in preventing further complications and maintaining vital functions.
Choice A rationale
While it is important to monitor blood glucose levels in diabetic ketoacidosis, it is not the immediate priority when the client is also experiencing hypoxia. Blood glucose testing does not directly address the oxygen deficiency, which needs urgent attention to prevent severe outcomes.
Choice B rationale
Administering a bronchodilator can help improve breathing in some cases; however, it is not the first step in managing hypoxia and diabetic ketoacidosis. The primary focus should be on ensuring a patent airway to facilitate adequate oxygen delivery.
Choice C rationale
Monitoring vital signs is essential in managing any acute condition; however, in this scenario, ensuring a clear airway to address hypoxia is the most critical intervention. Monitoring alone does not resolve the immediate issue of oxygen deprivation.
Correct Answer is ["A","B"]
Explanation
Choice A rationale: A blood glucose level of 55 mg/dL is critically low, indicating hypoglycemia. Immediate intervention is required to prevent potential complications such as loss of consciousness, seizures, or even death. Hypoglycemia in individuals with type 1 diabetes can be life-threatening and requires prompt treatment with fast-acting carbohydrates to restore normal blood glucose levels.
Choice B rationale: The client's report of shakiness, hunger, cool skin, and diaphoresis are classic symptoms of hypoglycemia. These symptoms correlate with the dangerously low blood glucose level and indicate an urgent need for intervention. Addressing these symptoms quickly can prevent further deterioration of the client's condition.
Choice C rationale: While the slight increase in temperature to 37.8°C (100°F) is noteworthy, it does not necessitate immediate intervention compared to the hypoglycemic event. Monitoring for any signs of infection or other issues is important, but it is not the highest priority in this scenario.
Choice D rationale: An oxygen saturation of 97% on room air is within normal limits and does not require immediate follow-up. There are no signs of respiratory distress or hypoxia that would necessitate urgent intervention in this case.
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