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?
Place the client in a supine position while resting.
Perform an ECG every 12 hours.
Draw a troponin level every 4 hours.
Obtain a cardiac rehabilitation consultation.
The Correct Answer is D
Choice A reason: Supine positioning risks respiratory strain post-myocardial infarction; semi-Fowler’s is preferred. Cardiac rehabilitation is appropriate. Assuming supine is correct risks discomfort or complications, critical to avoid in ensuring proper positioning and recovery support for clients 3 days post-acute myocardial infarction.
Choice B reason: ECG every 12 hours is excessive 3 days post-myocardial infarction unless symptomatic; daily or as-needed is standard. Rehabilitation consultation is key. Assuming frequent ECGs risks unnecessary testing, critical to prevent in focusing on recovery planning and rehabilitation for post-infarction clients.
Choice C reason: Troponin levels every 4 hours are unnecessary 3 days post-myocardial infarction, as levels peak earlier; rehabilitation is priority. Assuming frequent troponin checks risks redundant testing, critical to avoid in ensuring appropriate care focus on recovery and rehabilitation post-acute myocardial infarction.
Choice D reason: Obtaining a cardiac rehabilitation consultation 3 days post-myocardial infarction supports recovery through structured exercise and education, critical for preventing further events. This intervention promotes long-term cardiac health, essential for reducing readmissions, enhancing recovery, and improving quality of life in post-infarction clients.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Wearing gloves prevents nicotine absorption through the nurse’s skin during patch application, ensuring safety and preventing side effects like dizziness. This adheres to standard precautions, critical for occupational health, maintaining hygiene, and ensuring effective nicotine therapy for clients in smoking cessation programs.
Choice B reason: Removing the previous patch is correct but placing it in tissue is inadequate; it should be folded and disposed in a sharps container. Assuming tissue disposal is sufficient risks improper handling, potentially exposing others to nicotine, critical to avoid in safe patch management.
Choice C reason: Applying the patch within 1 hour of pouch removal is unnecessary; patches remain stable longer. Wearing gloves is priority. Assuming time restriction risks rushed application, potentially compromising technique, critical to prevent in ensuring safe and effective nicotine patch therapy for smoking cessation.
Choice D reason: Shaving hairy areas risks skin irritation; trimming is preferred before patch application. Wearing gloves is essential. Assuming shaving is correct risks skin damage, reducing patch adhesion, critical to avoid in ensuring proper application and effective nicotine delivery in smoking cessation therapy.
Correct Answer is A
Explanation
Choice A reason: Confirming the client’s perception of the crisis is the first step, establishing trust and understanding their emotional state, critical for effective intervention. This guides tailored support, essential for addressing depression in a situational crisis, ensuring therapeutic communication, and promoting coping in mental health care settings.
Choice B reason: Teaching relaxation techniques is useful but secondary to understanding the client’s crisis perception, which informs interventions. Assuming techniques are first risks misaligned support, potentially escalating distress, critical to avoid in ensuring effective crisis management for clients with depression experiencing situational stressors.
Choice C reason: Identifying strengths supports coping but follows confirming the client’s crisis perception, which sets the therapeutic foundation. Prioritizing strengths risks overlooking the client’s immediate emotional needs, potentially delaying effective intervention, critical to prevent in managing depression during a situational crisis in mental health care.
Choice D reason: Notifying a support person is secondary to understanding the client’s crisis perception, which guides initial intervention. Assuming notification is first risks bypassing the client’s perspective, potentially reducing trust, critical to avoid in ensuring client-centered care for depression in situational crisis management.
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