A nurse is evaluating a patient who is suffering from prostatic hypertrophy.
What symptoms associated with urinary retention should the nurse anticipate? (Choose all that apply)

Choice A rationale

A water heater temperature of 54.4°C (130°F) is a safety risk because it can cause burns. Older adults have thinner skin and are more susceptible to burns.

Choice B rationale

Electric cords behind furniture can be a safety risk because they can cause tripping or fire if the cords are damaged.

Choice C rationale

Throw rugs are a safety risk because they can slide underfoot and cause falls, especially in older adults who may have balance issues.

Choice D rationale

Raised toilet seats are not a safety risk. In fact, they are often recommended for older adults to prevent falls in the bathroom.

Choice E rationale

A bathtub with rails is not a safety risk. Rails can provide support and prevent falls when the older adult is entering or exiting the bathtub.

Choice A rationale

The priority action for a nurse when caring for a patient exhibiting symptoms of a myocardial infarction is to initiate oxygen therapy. Oxygen therapy is crucial because it increases the amount of oxygen in the blood, which can help reduce the heart’s workload and relieve pain. This intervention is aimed at reducing myocardial oxygen demand and improving oxygen supply to the ischemic myocardium.

Choice B rationale

Obtaining a blood sample is important as it can help diagnose a myocardial infarction. Blood tests can measure levels of certain proteins, such as troponins, in the bloodstream that can indicate heart muscle damage. However, this is not the immediate priority when compared to initiating oxygen therapy.

Choice C rationale

Attaching the leads for a 12-lead ECG is an important step in the assessment of a patient with suspected myocardial infarction. An ECG can show whether the heart muscle has been damaged and where the damage has occurred. However, this should be done after initiating oxygen therapy.

Choice D rationale

Inserting an IV catheter is a necessary step in the management of a myocardial infarction. It allows for the administration of medications and fluids as needed. However, it is not the first priority. The first priority is to stabilize the patient, which includes initiating oxygen therapy.