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 D
Explanation
Choice A reason: A mobile 24 inches above the crib is too high for a 1-week-old’s vision (8-12 inches is ideal), indicating misunderstanding. A ticking clock is soothing. Assuming mobile placement is correct risks reduced stimulation, critical to avoid in supporting infant development and parental education.
Choice B reason: Propping a bottle with a pillow risks choking or aspiration in a 1-week-old; holding is required. A ticking clock is correct. Assuming propping is safe risks infant safety, critical to prevent in ensuring proper feeding practices and parental education for newborns.
Choice C reason: Avoiding frequent holding risks neglecting bonding and comfort needs in a 1-week-old; responsive care is essential. A ticking clock is soothing. Assuming avoidance is correct risks developmental issues, critical to avoid in supporting infant emotional health and parental caregiving education.
Choice D reason: Placing a ticking clock nearby mimics womb sounds, soothing a 1-week-old, promoting sleep and comfort. This understanding is critical for infant well-being, supporting parental caregiving, ensuring a calming environment, and fostering healthy development in the early newborn period at home.
Correct Answer is D
Explanation
Choice A reason: Urine output of 20 mL/hr is below the desired 30 mL/hr during magnesium sulfate therapy, indicating potential toxicity or renal issues, not a therapeutic effect. Absence of eclampsia is the goal. Monitoring for low output risks missing seizure prevention, critical for maternal safety in preeclampsia management.
Choice B reason: Fetal heart rate of 116/min is within normal (110-160/min) but not a direct therapeutic effect of magnesium sulfate, which prevents seizures. Absence of eclampsia is key. Assuming heart rate is the focus risks overlooking maternal neurological status, critical for ensuring seizure prevention in preeclampsia treatment.
Choice C reason: Blood pressure of 150/92 mm Hg, while elevated, is not the primary therapeutic effect of magnesium sulfate, which targets seizure prevention, not hypertension. Absence of eclampsia is priority. Focusing on blood pressure risks neglecting seizure monitoring, critical for maternal safety in preeclampsia management with magnesium.
Choice D reason: Absence of eclampsia (seizures) is the primary therapeutic effect of magnesium sulfate in preeclampsia, stabilizing neuronal excitability, preventing life-threatening convulsions. Monitoring this ensures maternal safety, critical for preventing neurological damage, supporting fetal well-being, and guiding therapy adjustments in high-risk obstetric care.
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