A client is brought to the emergency department for unrelieved chest pain for 45 minutes. ECG performed by EMS suspects a non-ST elevation myocardial infarction (NSTEMI). Which of the following interventions is most important?
Apply oxygen, administer morphine, and place the client on bed rest with cardiac monitoring.
Have the client chew two aspirin 325 mg each, administer oxygen and bring the crash cart to the bedside.
Administer oxygen, give a dose of nitroglycerin sublingual, and follow with a nonsteroidal anti-inflammatory.
Begin a heparin drip, administer oxygen, and call the lab for stat troponin levels.
The Correct Answer is A
A. Apply oxygen, administer morphine, and place the client on bed rest with cardiac monitoring: These interventions prioritize reducing myocardial oxygen demand and alleviating ischemic pain in the acute phase of NSTEMI. Morphine acts as a potent analgesic and vasodilator, while oxygen improves tissue saturation. Bed rest and continuous monitoring ensure hemodynamic stability and rapid detection of dysrhythmias.
B. Have the client chew two aspirin 325 mg each, administer oxygen and bring the crash cart to the bedside: While aspirin is indicated for its antiplatelet effects, a dose of 650 mg exceeds the standard loading dose of 162 to 325 mg. Administering excessive aspirin increases the risk of gastrointestinal hemorrhage without providing additional cardiac benefit. The crash cart is necessary but secondary to immediate pharmacological stabilization.
C. Administer oxygen, give a dose of nitroglycerin sublingual, and follow with a nonsteroidal anti-inflammatory: Nonsteroidal anti-inflammatory drugs, excluding aspirin, are contraindicated in acute myocardial infarction because they increase the risk of myocardial rupture and mortality. Nitroglycerin helps with vasodilation, but the addition of an NSAID is harmful. This combination fails to provide the necessary sedation and potent analgesia required.
D. Begin a heparin drip, administer oxygen, and call the lab for stat troponin levels: Heparin and troponin levels are essential components of NSTEMI management but do not address the client's immediate, unrelieved pain. Anticoagulation prevents further thrombus formation but does not actively reduce the current ischemic workload. Immediate nursing priorities must focus on symptomatic relief and cardiac workload reduction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D"]
Explanation
A. Assess the patient's appetite and thirst: While loop diuretics can cause dehydration, appetite monitoring is not the primary nursing priority for managing loop diuretic therapy. Thirst may occur, but it is a subjective symptom rather than a critical objective indicator of electrolyte imbalance. Clinical focus remains on metabolic and hemodynamic stability.
B. Monitor magnesium levels, as ordered: Loop diuretics inhibit the reabsorption of cations in the thick ascending limb of the loop of Henle. This mechanism leads to increased urinary excretion of magnesium alongside water and sodium. Hypomagnesemia can predispose the client to cardiac arrhythmias and muscle tetany.
C. Assess the client for gastric distress including nausea, vomiting and diarrhea: These gastrointestinal symptoms are not the most common or significant adverse effects of furosemide administration. While they can occur with many medications, they do not reflect the primary pharmacological risks associated with diuretic-induced fluid shifts. Monitoring should prioritize renal function and electrolyte concentrations.
D. Monitor the client's potassium levels as ordered: Furosemide promotes significant potassium wasting by increasing delivery of solutes to the distal tubule. Hypokalemia is a frequent and dangerous complication that can lead to life-threatening cardiac conduction disturbances. Frequent serum monitoring is essential to ensure the safety of the heart failure patient.
Correct Answer is B
Explanation
A. Macaroni and cheese: This food is high in carbohydrates and fats but does not contain significant amounts of Vitamin K. While not particularly heart-healthy, it does not directly interfere with the mechanism of warfarin. Patients on anticoagulants do not need to avoid this food specifically for PT/INR stability.
B. Kale chips: Kale is extremely high in Vitamin K, which is the direct physiological antagonist to warfarin. Consuming large or inconsistent amounts of leafy greens can lower the INR, making the blood more prone to clotting and reducing the medication's efficacy. Patients must maintain a consistent intake of Vitamin K to ensure stable anticoagulation levels.
C. Fast food burger and fries: High-fat meals can affect overall cardiovascular health and lipid levels but do not have a direct, acute impact on Vitamin K levels or warfarin metabolism. While the nurse should encourage better nutrition, this meal does not present the same immediate risk to PT/INR monitoring as high-Vitamin K foods.
D. Fruit salad: Most fruits are naturally low in Vitamin K and are safe for patients taking warfarin to consume. Fruit provides essential vitamins and fiber without interfering with the anticoagulant effects of the medication. This is a healthy dietary choice that does not require specific education regarding warfarin interactions.
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