A client has chest pain rated 8/10 as stated by the patient. The 12-lead ECG reveals ST elevation in the inferior leads and the lab results reveal cardiac enzyme levels are elevated. What is the highest priority for nursing management of this client at this time?
Monitor daily weights and urine output.
Administer TPA to prevent further damage as a result of a clot.
Provide client education on medications and diet to prevent recurrence.
Reduce pain and myocardial oxygen demand.
The Correct Answer is D
A. Monitor daily weights and urine output.
Monitoring daily weights and urine output is an important aspect of managing heart failure or other cardiac conditions. However, in the context of a client with chest pain, ST elevation, and elevated cardiac enzymes (indicating a myocardial infarction), the immediate focus is on addressing the acute event and reducing myocardial oxygen demand.
B. Administer TPA to prevent further damage as a result of a clot.
Tissue plasminogen activator (TPA) is a thrombolytic medication that can be administered to dissolve blood clots in the coronary arteries during a myocardial infarction. However, the administration of TPA has a specific timeframe within which it is most effective. It is crucial to know the elapsed time since the onset of symptoms, and there are specific criteria and contraindications for its use.
C. Provide client education on medications and diet to prevent recurrence.
Client education on medications, lifestyle modifications, and dietary changes is an essential component of long-term management for preventing recurrence of cardiovascular events. However, during the acute phase of a myocardial infarction, the immediate priority is to stabilize the client and address the acute event, with education being a secondary consideration.
D. Reduce pain and myocardial oxygen demand.
During the acute phase of a myocardial infarction, reducing pain and myocardial oxygen demand is the highest priority. This is typically achieved through the administration of medications such as nitroglycerin for vasodilation and opioids for pain relief. Other interventions to optimize oxygen supply and demand, such as supplemental oxygen and reperfusion strategies, may also be considered.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Obtain a sputum sample:
This option is more relevant when the client is experiencing cough with sputum production, which might suggest respiratory issues. However, in the context of coughing after eating or drinking, the primary concern is likely related to the swallowing process rather than respiratory conditions.
B. Inspect the client’s tongue and mouth:
While inspecting the tongue and mouth is a good practice for assessing oral health, it may not directly address the issue of coughing after eating or drinking, which is more indicative of potential swallowing difficulties.
C. Perform a swallowing assessment:
This is the most appropriate option for the given scenario. A swallowing assessment helps identify any abnormalities or difficulties in the swallowing process, which could contribute to the client's coughing after eating or drinking.
D. Assess the client’s nutritional status:
While assessing nutritional status is important for overall health, it may not directly address the immediate concern of coughing after eating or drinking. Nutritional status assessment is a broader aspect of care.
Correct Answer is B
Explanation
A. “I will have canned chicken noodle soup with crackers and an apple for lunch.”
This option may not be the best choice for a low-sodium diet. Canned soups often contain high levels of sodium.
B. “I will have a tossed salad with cheese and croutons for lunch.”
This option is a better choice, as salads with fresh vegetables can be lower in sodium compared to other options.
C. “I will have a ham and cheese sandwich for lunch.”
Ham and cheese are generally high in sodium, so this would not be a suitable choice for a low-sodium diet.
D. “I will have a baked potato with broiled chicken for dinner.”
This option seems to be a good choice. Baked potato and broiled chicken can be part of a low-sodium meal.
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