A client is admitted to the telemetry unit with an episode of substernal chest pain.
His diagnostic studies reveal an elevated ST segment on the electrocardiogram (ECG) and an elevated cardiac troponin level.
What would be an appropriate initial nursing goal?
Reduce anxiety and relieve pain.
Improve myocardial oxygenation and reduce cardiac workload.
Eliminate family stressors and provide a calm environment.
Start the client on a low-sodium diet and decrease fluid intake.
The Correct Answer is B
Choice A rationale
While reducing anxiety and relieving pain are important aspects of care, they are not the primary goal for a client with an elevated ST segment on the ECG and an elevated cardiac troponin level. These findings indicate myocardial injury, which requires interventions to improve myocardial oxygenation and reduce cardiac workload.
Choice B rationale
The primary goal for a client with an elevated ST segment on the ECG and an elevated cardiac troponin level is to improve myocardial oxygenation and reduce cardiac workload. This can be achieved through medications, oxygen therapy, and bed rest.
Choice C rationale
Eliminating family stressors and providing a calm environment can contribute to reducing anxiety and promoting relaxation, but it is not the primary goal in this situation.
Choice D rationale
Starting the client on a low-sodium diet and decreasing fluid intake are interventions for managing heart failure, not for an acute myocardial injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Propranolol (Inderal) is a beta-adrenergic receptor blocker, also known as a beta-blocker. Beta-blockers can increase airway reactivity and may interfere with the activity of beta-agonists. They should be used with great caution or not at all in patients with chronic asthma.
However, beta blockers are safe for use in most patients with COPD, but less so in patients with asthma. Therefore, Propranolol (Inderal) is not recommended for patients with chronic obstructive pulmonary disease (COPD) and asthma.
Choice B rationale
Captopril (Capoten) is an ACE inhibitor, which is among the most widely used antihypertensive drugs. They are not contraindicated in asthma or COPD, but they can induce a bothersome cough that, although not damaging to the lungs, can be confused with cough due to underlying pulmonary diseases such as asthma and COPD1.
Choice C rationale
Diltiazem (Cardizem) is a calcium antagonist. There is no specific contraindication for using calcium antagonists in patients with COPD or asthma. These medications work by relaxing the muscles of your heart and blood vessels, but they do not have a direct effect on airway reactivity or lung function.
Choice D rationale
Hydrochlorothiazide (HydroDIURIL) is a diuretic. Diuretics help your body get rid of excess salt and water, primarily by stimulating your kidneys. They do not have a direct effect on airway reactivity or lung function, and there is no specific contraindication for using them in patients with COPD or asthma.
Correct Answer is D
Explanation
Choice A rationale
Serum hemoglobin of 14.7 g/dL is within the normal range for adults, which is typically 12.0 to
16.0 g/dL for women and 13.5 to 17.5 g/dL for men. Hemoglobin is a protein in red blood cells that carries oxygen throughout the body. While it’s important to monitor hemoglobin levels, a value of 14.7 g/dL does not raise immediate concerns related to hypertension.
Choice B rationale
A blood glucose level of 96 mg/dL is considered normal. The normal range for fasting blood glucose is between 70 and 100 mg/dL1. Blood glucose levels are important to monitor, especially in patients with diabetes, but a value of 96 mg/dL is not immediately concerning in the context of hypertension.
Choice C rationale
A serum potassium level of 4.5 mEq/L is within the normal range, which is typically 3.6 to 5.2 mEq/L1. Potassium is an essential electrolyte that helps regulate heart and muscle contractions and maintain fluid balance in the body. While it’s important to monitor potassium levels, a value of 4.5 mEq/L does not raise immediate concerns related to hypertension.
Choice D rationale
A serum creatinine level of 2.8 mg/dL is high. Creatinine is a waste product that’s produced by your muscles and filtered out of your blood by your kidneys. High levels of creatinine can indicate that the kidneys aren’t working properly, which can be a complication of hypertension. Therefore, this result is the most important to communicate to the healthcare provider.
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