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.

Answer and Explanation

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.

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Correct Answer is ["B","C","D","E"]

Explanation

A. Administer antibiotics

Administering antibiotics is not a direct intervention for preventing atelectasis. Antibiotics are typically prescribed to treat bacterial infections, and atelectasis is more related to lung collapse or incomplete lung expansion.

B. Encourage increased oral fluid intake

Adequate hydration is important for maintaining the moisture of respiratory secretions. This helps prevent mucus from becoming thick and sticky, making it easier for the patient to cough and clear the airways.

C. Early mobilization after surgery

Early mobilization, including activities such as getting out of bed and walking, helps improve lung expansion. It promotes better ventilation and prevents areas of the lungs from collapsing, reducing the risk of atelectasis.

D. Frequent turning of the patient

Turning the patient regularly is crucial for preventing pooling of respiratory secretions in dependent areas of the lungs. By changing the patient's position, nurses can facilitate drainage and ventilation throughout the lungs, minimizing the risk of atelectasis.

E. Use of incentive spirometry

Incentive spirometry is a breathing exercise device that encourages the patient to take slow, deep breaths. This helps expand the lungs and prevents atelectasis by maintaining lung volume and promoting alveolar recruitment.

A. Maintaining a diet high in dairy to increase protein necessary to prevent organ damage B. Use of strategies to prevent falls stemming from postural hypotension C. Limiting exercise to avoid injury that can be caused by increased intracranial pressure D. Increasing fluids to avoid extracellular volume depletion from the diuretic effects of the beta-blocker

Correct Answer is B

Explanation

A. Maintaining a diet high in dairy to increase protein necessary to prevent organ damage

Explanation: This statement is not accurate. While a balanced diet is important, there is no specific recommendation to maintain a diet high in dairy to prevent organ damage related to hypertension.

B. Use of strategies to prevent falls stemming from postural hypotension

Explanation: This is a correct and important consideration. Beta-blockers can cause postural hypotension (a drop in blood pressure upon standing), and strategies to prevent falls, such as rising slowly from a sitting or lying position, are crucial.

C. Limiting exercise to avoid injury that can be caused by increased intracranial pressure

Explanation: This statement is not accurate. Exercise is generally beneficial for individuals with hypertension, and beta-blockers do not cause increased intracranial pressure.

D. Increasing fluids to avoid extracellular volume depletion from the diuretic effects of the beta-blocker

Explanation: This statement is not accurate. Beta-blockers are not typically associated with diuretic effects. Diuretics are a different class of medications commonly used for hypertension.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nursing student is reviewing interventions which are part of nursing care and prevention of atelectasis. What are some of the interventions nurses can do to prevent atelectasis? (SELECT ALL THAT APPLY)

Correct Answer is ["B","C","D","E"]

Explanation

An older adult is newly diagnosed with primary hypertension, and has just been started on a beta-blocker. What information should the nurse include in the health education for this client?

Correct Answer is B

Explanation

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