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 D
Explanation
A. Request an interpreter of a different sex from the client: The interpreter’s sex should ideally match the client’s preference for comfort and privacy, but this is not the first action. The priority is understanding facility policy and proper use of interpreters.
B. Request a family member or friend to interpret information for the client: Using family or friends can lead to miscommunication, breaches of confidentiality, or bias. Professional interpreters are preferred to ensure accurate and complete information.
C. Direct attention toward the interpreter when speaking to the client: When using an interpreter, the nurse should maintain eye contact and direct communication to the client, not the interpreter, to foster rapport and respect.
D. Review the facility policy about the use of an interpreter: Reviewing policy ensures that the nurse follows legal, ethical, and professional guidelines for language access services. This is the appropriate first action before arranging or using an interpreter.
Correct Answer is {"A":{"answers":"B,C"},"B":{"answers":"C"},"C":{"answers":"A,B,C"},"D":{"answers":"A,B,C"}}
Explanation
- Lymphadenopathy: Generalized lymphadenopathy, or swelling of the lymph nodes, is a common symptom of measles and rubella, but not typically a defining feature of fifth disease.
- Koplik spots in the mouth: Pathognomonic for measles, appearing as tiny white lesions on the buccal mucosa before the rash. Their presence essentially confirms measles over other viral exanthems.
- Red rash on the face: Occurs in all three illnesses but with different patterns — measles starts at the hairline and spreads downward, rubella begins on the face and spreads quickly, and fifth disease presents with a “slapped cheek” appearance before spreading.
- Fever: Common to all three conditions but differs in severity — measles typically produces higher fevers, rubella causes mild fever, and fifth disease may have low-grade fever or none.
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