A 46-year-old male client who had a myocardial infarction (MI) 24 hours ago comes to the nurse's station fully dressed and wanting to go home. He tells
the nurse that he is feeling much better at this time. Based on this behavior, which client problem should the nurse include in the plan of care?

Choice A reason: Keeping the bed in the lowest position and initiating seizure and fall precautions is not an immediate action for the nurse to take. Seizure and fall precautions are measures that prevent injury or harm to the client in case of a seizure or a fall. Seizure and fall precautions include lowering the bed, padding the side rails, removing any objects that may cause injury, and having suction and oxygen equipment ready. However, these precautions are not specific to the client's condition and do not address the underlying cause.

Choice B reason: Placing an indwelling urinary catheter and measuring strict intake and output is not an urgent action for the nurse to take. An indwelling urinary catheter is a tube that drains urine from the bladder into a collection bag. Measuring intake and output is a way of monitoring fluid balance and kidney function. However, these interventions are not essential for the client's condition and may increase the risk of infection or trauma.

Choice C reason: Maintaining elevated positioning of the dependent joints on affected side is not a relevant action for the nurse to take. Dependent joints are joints that are below the level of the heart, such as the ankles or wrists. Elevating dependent joints can help reduce swelling or pain by improving blood flow and drainage. However, this intervention is not related to the client's condition and does not improve neurological function.

Choice D reason: This is the correct answer because starting two large bore IV catheters and reviewing inclusion criteria for IV fibrinolytic therapy is a critical action for the nurse to take. IV catheters are devices that allow access to the bloodstream for fluid or medication administration. Fibrinolytic therapy is a treatment that dissolves blood clots that may block blood flow to vital organs, such as the brain or heart. The client's symptoms suggest a possible stroke, which is a medical emergency that occurs when blood flow to a part of the brain is interrupted, causing brain tissue damage or death. The nurse should start two large bore IV catheters in case one fails or becomes occluded, and review inclusion criteria for IV fibrinolytic therapy, such as onset of symptoms, blood pressure, blood glucose, coagulation status, and history of bleeding or trauma, to determine if the client is eligible for this potentially life-saving treatment.

Choice A reason: Administering a half dose now is not a safe instruction for the nurse to provide, as this can result in overdosing or underdosing the infant, depending on how much of the medicine was absorbed or expelled. This is a contraindicated choice.

Choice B reason: Giving another dose is not a prudent instruction for the nurse to provide, as this can cause digoxin toxicity, which can be life-threatening for the infant. This is another contraindicated choice.

Choice C reason: Mixing the next dose with food is not a relevant instruction for the nurse to provide, as this does not address the current situation and can affect the absorption and effectiveness of digoxin. This is a distractor choice.

Choice D reason: Withholding this dose is a sensible instruction for the nurse to provide, as this can prevent adverse effects and allow the infant's serum digoxin level to be checked before giving another dose. Therefore, this is the correct choice.