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    Med Surg 2 Proctored ExamQuestion 43
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    Med Surg 2 Proctored Exam

    A client in the hospital after suffering a myocardial infarction and has bathroom privileges. The nurse assists the client to the bathroom and notes the client's 02 saturation to be 96%, pulse 88 beats/min and respiratory rate 16 breaths/min after returning to bed. What action by the nurse is best?

    Explanation & Rationale

    A. Obtain a bedside commode: A bedside commode may be considered for clients who are weak, at risk of falls, or unable to safely ambulate, but the client’s vital signs (O₂ saturation 96%, pulse 88 bpm, respiratory rate 16) are within normal limits after ambulating to the bathroom. There is no indication that the client cannot safely use the bathroom independently. B. Suggest the client use a bedpan: Bedpan use is generally reserved for clients who are immobile, critically ill, or have activity restrictions. Since this client tolerated ambulation to the bathroom without oxygen desaturation, tachycardia, or dyspnea, restricting them to a bedpan would unnecessarily limit mobility and independence. C. Allow continued bathroom privileges: The client’s vital signs after ambulation are stable, demonstrating hemodynamic tolerance. Allowing continued bathroom privileges promotes independence, mobility, and comfort while monitoring for any changes in cardiac or respiratory status. This aligns with post-MI activity guidelines, which encourage gradual mobilization. D. Administer oxygen at 2 L/min: The client’s oxygen saturation is 96%, which is within the normal target range for a post-MI patient (typically ≥ 92%). Administering supplemental oxygen is not indicated unless the client develops hypoxemia, dyspnea, or other clinical signs of oxygen desaturation.

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