A client has presented to the emergency department with an acute myocardial infraction (MI). What action by the nurse is best for optional client outcomes?
Give the client a nonenteric coated aspirin.
Notify the Rapid Response Team immediately.
Obtain an electrocardiogram (ECG) within 20 minutes.
Prepare to administer thrombolytics within 60 minutes.
The Correct Answer is C
A. Give the client a nonenteric coated aspirin: Administering aspirin is important to reduce platelet aggregation in acute MI, but it should follow immediate assessment and ECG confirmation. It is part of initial management, not the first step for optimal outcomes.
B. Notify the Rapid Response Team immediately: While escalation is important for deteriorating patients, a client presenting with chest pain suggestive of MI should be prioritized for diagnostic confirmation and timely interventions.
C. Obtain an electrocardiogram (ECG) within 20 minutes: Rapid ECG acquisition is critical for confirming the diagnosis of acute MI and guiding urgent interventions. Achieving this within 20 minutes is a key quality measure associated with improved outcomes, making it the priority action.
D. Prepare to administer thrombolytics within 60 minutes: Thrombolytic therapy is indicated for certain types of MI (STEMI) but should be initiated after diagnostic confirmation via ECG. Preparing for administration is important but follows timely assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Calculation:
Ordered Dose (D) = 10 mg/hr
Available Dose (H) = 125 mg
Quantity (Q) = 100 mL
Flow Rate (mL/hr) = (Dose Ordered (D) / Dose Available (H)) x Quantity (Q)
= (10 mg / 125 mg) x 100 mL
= 0.08 x 100 mL
= 8 mL/hr
Correct Answer is B
Explanation
A. Increase 0.9% Normal Saline infusion to 250 mL/hr per protocol: The client’s low CVP and PAWP, hypotension, tachycardia, and dry mucous membranes indicate hypovolemia and dehydration, likely due to sepsis with fluid losses. Increasing isotonic fluid infusion helps restore intravascular volume, improve perfusion, and stabilize hemodynamics.
B. Administer Furosemide (Lasix) 20 mg IV push: Furosemide is contraindicated because it promotes diuresis and would worsen the client’s hypovolemia. The client’s low filling pressures and hypotension indicate severe fluid deficit, not overload. Administering Lasix could precipitate hypoperfusion, acute kidney injury, and cardiovascular collapse.
C. Collect UA for culture and sensitivity: Urinary tract infection is a common cause of sepsis in older adults. Obtaining a urine culture helps identify the causative organism and guide antibiotic therapy, making this order appropriate and necessary for diagnostic accuracy.
D. Collect blood cultures and start Vancomycin 1 gm IV: Blood cultures are essential before antibiotic administration to identify systemic infection sources. Starting broad-spectrum antibiotics like vancomycin promptly after collection aligns with sepsis management protocols and supports early infection control.
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