A client arrives at the emergency department reporting unrelieved chest pain that has persisted for approximately 20 minutes. Upon assessment, the nurse notes the client is diaphoretic and exhibiting signs of distress. Given the urgency to minimize potential cardiac damage, which combination of interventions should the nurse prioritize for immediate administration?
Oxygen and beta-adrenergic blockers
Thrombolytics (fibrinolytics), oxygen administration, and nonsteroidal anti-inflammatories
Clopidogrel, Furosemide, and Nitroglycerin
Nitroglycerin, aspirin, and oxygen
The Correct Answer is D
A. Oxygen may be indicated, but beta-adrenergic blockers are not the highest priority for immediate management of acute chest pain in the emergency setting.
B. Thrombolytics are only indicated for confirmed ST-elevation myocardial infarction (STEMI), and NSAIDs are not appropriate for acute cardiac pain.
C. Clopidogrel may be used in some cases, and furosemide is for fluid overload; however, this combination does not address immediate myocardial ischemia.
D. Nitroglycerin, aspirin, and oxygen are the priority interventions for acute chest pain suggestive of myocardial infarction. Oxygen improves oxygenation, nitroglycerin reduces myocardial oxygen demand, and aspirin inhibits platelet aggregation to limit clot progression.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. An increase in pulse rate with minimal activity indicates the heart is compensating for decreased cardiac output due to valvular insufficiency, making it a direct indicator for this nursing diagnosis.
B. Fever, chills, and diaphoresis are signs of infection but do not directly indicate decreased cardiac output.
C. Petechiae are vascular manifestations of infective endocarditis but are not related to cardiac output.
D. Low urine output may indicate renal perfusion issues, but it is a secondary consequence rather than a direct assessment finding of decreased cardiac output.
Correct Answer is D
Explanation
A. Third-degree AV block is a bradyarrhythmia and typically has a wide QRS due to ventricular escape rhythm.
B. Ventricular tachycardia originates in the ventricles, producing a wide QRS complex.
C. Ventricular fibrillation is characterized by chaotic ventricular activity with no discernible QRS complexes.
D. Supraventricular tachycardia originates above the ventricles (atria or AV node) and produces a narrow QRS complex, making it the classic example of narrow complex tachycardia.
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