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 B
Explanation
Choice A reason: Supervising return demonstration follows teaching, not initial assessment; determining knowledge is first. Assuming demonstration is the first step risks ineffective education, potentially leading to misuse, critical to avoid in ensuring proper diaphragm use and contraception efficacy for female clients.
Choice B reason: Determining the client’s knowledge about diaphragm use is the first step, guiding tailored education and ensuring effective use. This assessment is critical for addressing gaps, promoting adherence, preventing contraceptive failure, and supporting informed decision-making in female clients requesting diaphragms for contraception.
Choice C reason: Teaching insertion follows assessing knowledge, which identifies educational needs. Assuming teaching is first risks overlooking client understanding, potentially leading to incorrect use, critical to prevent in ensuring effective diaphragm contraception and client safety in reproductive health care.
Choice D reason: Documenting understanding is a later step after assessing and teaching; determining knowledge is priority. Assuming documentation is first risks premature recording, potentially missing educational needs, critical to avoid in ensuring comprehensive diaphragm education and effective contraception for female clients.
Correct Answer is D
Explanation
Choice A reason: Repositioning the NG tube is a later step; checking suction function is first, as equipment failure is a common cause of no drainage. Assuming repositioning is initial risks delaying simple fixes, potentially prolonging discomfort, critical to avoid in ensuring effective gastric decompression.
Choice B reason: Injecting air and aspirating is a troubleshooting step but follows checking suction equipment, which may resolve no drainage. Assuming air injection is first risks unnecessary intervention, potentially causing discomfort, critical to prevent in ensuring efficient NG tube management for gastric decompression.
Choice C reason: Instilling irrigation solution is a later step after confirming suction function, as equipment issues are more common. Assuming irrigation is first risks clogging or discomfort, critical to avoid in ensuring proper NG tube function and effective gastric decompression in clients with non-draining tubes.
Choice D reason: Checking suction equipment function is the first step for a non-draining NG tube, as equipment failure is a common issue, easily corrected. This ensures effective decompression, critical for preventing gastric distention, supporting client comfort, and guiding further troubleshooting in managing NG tube care.
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