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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Correct Answer is B
Explanation
Rationale:
A. How to change the tracheostomy dressing using clean technique: Tracheostomy dressings should be changed using sterile technique, not clean technique, to prevent infection and protect the airway. Teaching clean technique would be inappropriate.
B. How to operate the portable suction machine: Suctioning is a critical skill for maintaining airway patency and preventing respiratory complications. Teaching the partner how to operate the suction machine ensures they can assist safely at home if needed.
C. How to change the nondisposable tracheostomy tube daily: Nondisposable tracheostomy tubes are not typically changed daily; frequent changes can damage the stoma or airway. Tube changes are usually performed by trained healthcare personnel.
D. How to secure the tracheostomy tube with ties at the back of the neck: Ties should be secured in a way that avoids pressure or friction on the back of the neck, typically fastening at the sides. Focusing on back-of-neck placement could lead to skin breakdown or discomfort.
Correct Answer is B
Explanation
A. Document the client's level of understanding about potential adverse effects: Documentation is important but should occur after assessing the client’s knowledge and providing teaching.
B. Determine the client's knowledge about diaphragm use: Assessment is the first step in the nursing process. Understanding the client’s baseline knowledge allows the nurse to tailor teaching and identify misconceptions before providing instruction.
C. Supervise return demonstration of diaphragm use: Return demonstration evaluates learning but is only appropriate after teaching and assessment have been completed.
D. Teach the client how to insert the diaphragm: Teaching is essential but should follow assessment of the client’s current understanding to ensure the instruction is effective and appropriate.
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