A nurse is planning care for a male client who is postoperative following a hernia repair. Which of the following actions should the nurse include in the plan?

Rationale for Correct Choices

• Administer oxygen at 2 L/min via nasal cannula: The client’s oxygen saturation of 92% indicates mild hypoxemia, which can worsen myocardial ischemia. Administering low-flow oxygen enhances myocardial oxygen delivery and helps reduce chest pain and tissue damage.

• Administer sublingual nitroglycerin: After oxygen therapy, sublingual nitroglycerin is the next appropriate step to relieve ischemic chest pain. It dilates coronary arteries, improves blood flow, and reduces myocardial oxygen demand. The nurse should monitor blood pressure and pain relief closely after administration.

Rationale for Incorrect Choices

• Request a prescription for an increase in statin medication: Although the client’s total cholesterol and LDL levels are elevated, statin adjustment is a long-term management measure. It does not address the acute chest pain or compromised oxygenation that the client is currently experiencing.

• Prepare the client for cardiac catheterization: While cardiac catheterization may be needed if myocardial infarction is confirmed, immediate stabilization of oxygen and pain takes priority. The nurse must first implement emergency interventions before preparing for invasive procedures.

• Request a prescription for a beta-blocker: Beta-blockers help lower heart rate and myocardial oxygen demand but are not administered during initial emergency management. They are prescribed only after the client is stabilized and contraindications have been ruled out.

• Checking a STAT cardiac troponin: Checking a STAT cardiac troponin is an important diagnostic action to rule in or out an acute myocardial infarction, however, clinical management of acute symptoms takes precedence over waiting for a laboratory result.

Rationale:
A. Discuss future treatment options with the client's health care surrogate: The client has decision-making capacity and advance directives in place, so the nurse should honor the client’s wishes rather than deferring to the surrogate.

B. Encourage the client to complete a final hemodialysis treatment: Encouraging treatment contradicts the client’s expressed wishes and advance directives, violating the client’s autonomy and right to refuse care.

C. Contact the client's family to discuss the decision: Family input may be supportive, but the client’s decisions take priority. Involving the family without the client’s consent may undermine autonomy.

D. Discuss possible options for discharge with the client: The nurse should focus on supporting the client’s choices, including end-of-life care and hospice or palliative services, and discuss discharge options that align with the client’s wishes.