A client is admitted to the telemetry unit due to an episode of substernal chest pain.
Diagnostic tests reveal an elevated ST segment on the electrocardiogram (ECG) and an increased cardiac troponin level.
What would be an appropriate initial nursing intervention?
Reduce anxiety and alleviate pain.
Enhance myocardial oxygenation and decrease cardiac workload.
Remove family stressors and provide a tranquil environment.
Initiate a low-sodium diet and limit fluid intake.
The Correct Answer is B
Choice A rationale
While reducing anxiety and alleviating pain are important, they are not the most appropriate initial nursing intervention for a client with substernal chest pain, elevated ST segment on the ECG, and increased cardiac troponin level.
Choice B rationale
Enhancing myocardial oxygenation and decreasing cardiac workload are crucial initial nursing interventions for a client presenting with these symptoms. These actions can help prevent further damage to the heart muscle.
Choice C rationale
Removing family stressors and providing a tranquil environment, while beneficial, are not the most appropriate initial nursing interventions for a client with these symptoms.
Choice D rationale
Initiating a low-sodium diet and limiting fluid intake are important for managing heart failure, but they are not the most appropriate initial nursing interventions for a client with these symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Iron supplements for anemia do not typically interact with warfarin (Coumadin). Iron is a mineral that is essential for the production of red blood cells, and supplements are often prescribed to patients with anemia to increase their iron levels. While it’s important for healthcare providers to be aware of all medications and supplements a patient is taking, iron supplements are not known to diminish the effects of warfarin.
Choice B rationale
Furosemide (Lasix) is a diuretic medication used to treat fluid retention. It works by causing the kidneys to get rid of unneeded water and salt from the body into the urine. While furosemide can interact with other medications, it is not known to diminish the effects of warfarin.
Choice C rationale
Simvastatin (Zocor) is a medication used to control cholesterol levels. It works by slowing the production of cholesterol in the body to decrease the amount of cholesterol that may build up on the walls of the arteries and block blood flow to the heart, brain, and other parts of the body. Simvastatin does not typically interact with warfarin to diminish its effects.
Choice D rationale
Yaz (drospirenone/estradiol) is an oral contraceptive that contains estrogen. Estrogen can potentially increase the effects of warfarin, leading to an increased risk of bleeding. Therefore, if a patient taking warfarin also takes Yaz, it could potentially diminish the effects of warfarin, making it less effective. This is why it’s important for healthcare providers to be aware of all medications a patient is taking, including oral contraceptives.
Correct Answer is A
Explanation
Choice A rationale
The apical pulse, also known as the point of maximal impulse (PMI), is located at the fifth intercostal space at the left midclavicular line. This is the location where the heartbeat is strongest and is the standard location for assessing the apical heart rate.
Choice B rationale
Placing the stethoscope directly over the heart on the sternum is not the standard method for assessing the apical heart rate. While the sternum is close to the heart, it is not the location where the heartbeat is strongest or most easily heard.
Choice C rationale
The right side at the midclavicular line, fourth intercostal space, is not the standard location for assessing the apical heart rate. The heart is located more towards the left side of the chest, and the apical pulse is typically not as easily heard on the right side.
Choice D rationale
The midaxillary line on the left side is not the standard location for assessing the apical heart rate. While this location is on the left side of the chest, it is not where the heartbeat is strongest or most easily heard.
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