A nurse is planning care for a client who is recovering from an acute myocardial infarction that occurred 3 days ago. Which of the following interventions should the nurse include?
Perform an ECG every 12 hr.
Obtain a cardiac rehabilitation consultation.
Draw a troponin level every 4 hr.
Place the client in a supine position while resting.
The Correct Answer is B
Rationale:
A. Perform an ECG every 12 hr: Frequent ECGs are typically done during the acute phase to monitor for arrhythmias, but by day 3 post-MI, continuous or as-needed monitoring is more appropriate unless new symptoms occur.
B. Obtain a cardiac rehabilitation consultation: Early involvement of cardiac rehab supports gradual activity progression, lifestyle modification, and psychosocial support, improving long-term outcomes after MI.
C. Draw a troponin level every 4 hr: Troponin testing is most useful for diagnosing and trending damage during the first 24 hours; by day 3, levels have usually peaked and are declining.
D. Place the client in a supine position while resting: Supine positioning can increase cardiac workload; a semi-Fowler's position is preferred to reduce venous return and ease breathing.
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Related Questions
Correct Answer is C
Explanation
A. Bleeding gums: Mild bleeding gums can occur during pregnancy due to increased vascularity and hormonal changes. While uncomfortable, this finding is generally not urgent and can be managed with routine oral care.
B. Fundal height of 26 cm: A fundal height slightly above the gestational age (24 weeks vs. 26 cm) may be within normal variation, especially if the client has a larger fetus or multiple gestations. It should be monitored but is not immediately concerning.
C. Periorbital edema: Swelling around the eyes can be an early sign of preeclampsia, a potentially serious pregnancy complication. This finding should be reported promptly to the provider for further assessment and management.
D. White vaginal discharge: Mild, white, and non-odorous discharge (leukorrhea) is common during pregnancy due to hormonal changes. It is typically considered normal unless accompanied by odor, itching, or irritation.
Correct Answer is A
Explanation
A. A client who is taking warfarin and has started to breastfeed: Warfarin passes into breast milk in very small amounts and is generally considered compatible with breastfeeding. However, the infant’s coagulation status should be monitored, and follow-up with the healthcare provider is appropriate to ensure safety.
B. A client who is taking bumetanide and reports an increase in urinary frequency: Increased urination is an expected pharmacologic effect of loop diuretics like bumetanide. This finding does not require follow-up unless accompanied by other concerning symptoms.
C. A client who received a Mantoux test 48 hr ago and has an induration: A positive Mantoux test requires interpretation by a healthcare provider, but the presence of induration alone is a normal finding that triggers standard follow-up for tuberculosis screening.
D. A client who is scheduled for a colonoscopy and is taking sodium phosphate: Sodium phosphate is commonly used as a bowel prep for colonoscopy. As long as the client follows the prescribed instructions and has no contraindications, this does not require additional follow-up.
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