A nurse in the emergency department is attending to a patient exhibiting symptoms of a myocardial infarction. Which of the following actions should the nurse prioritize?

Initiate oxygen therapy.

Obtain a blood sample.

Attach the leads for a 12-lead ECG.

Insert an IV catheter.

Answer and Explanation

The Correct Answer is A

Choice A rationale

The priority action for a nurse when caring for a patient exhibiting symptoms of a myocardial infarction is to initiate oxygen therapy. Oxygen therapy is crucial because it increases the amount of oxygen in the blood, which can help reduce the heart’s workload and relieve pain. This intervention is aimed at reducing myocardial oxygen demand and improving oxygen supply to the ischemic myocardium.

Choice B rationale

Obtaining a blood sample is important as it can help diagnose a myocardial infarction. Blood tests can measure levels of certain proteins, such as troponins, in the bloodstream that can indicate heart muscle damage. However, this is not the immediate priority when compared to initiating oxygen therapy.

Choice C rationale

Attaching the leads for a 12-lead ECG is an important step in the assessment of a patient with suspected myocardial infarction. An ECG can show whether the heart muscle has been damaged and where the damage has occurred. However, this should be done after initiating oxygen therapy.

Choice D rationale

Inserting an IV catheter is a necessary step in the management of a myocardial infarction. It allows for the administration of medications and fluids as needed. However, it is not the first priority. The first priority is to stabilize the patient, which includes initiating oxygen therapy.

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Correct Answer is D

Explanation

Choice A rationale

Vitamin K is not the antidote for heparin. It is used to reverse the effects of warfarin, which is a vitamin K antagonist.

Choice B rationale

Iron is not related to the reversal of heparin. It is a mineral that is crucial for many bodily functions, including the transport of oxygen in the blood.

Choice C rationale

Glucagon is a hormone that raises the level of glucose in the blood. It is not used as an antidote for heparin.

Choice D rationale

Protamine is the correct choice. Protamine sulfate is a drug that reverses the anticoagulant effects of heparin by binding to it and forming a stable complex, thereby neutralizing its anticoagulant activity.

A. A patient who has streptococcal pharyngitis B. A patient who has scabies C. A patient who has measles D. A patient who has pertussis

Correct Answer is C

Explanation

Choice A rationale

Streptococcal pharyngitis, also known as strep throat, is a bacterial infection that causes inflammation and pain in the throat. This condition is spread through respiratory droplets, not through the air, and does not require airborne precautions.

Choice B rationale

Scabies is caused by a mite infestation, not an airborne pathogen. It is spread through direct skin-to-skin contact and does not require airborne precautions.

Choice C rationale

Measles is a highly contagious virus that lives in the nose and throat mucus of an infected person. It can spread to others through coughing and sneezing, and the measles virus can live for up to two hours in an airspace where the infected person coughed or sneezed. Therefore, a patient with measles requires airborne precautions.

Choice D rationale

Pertussis, also known as whooping cough, is a highly contagious respiratory disease caused by the bacterium Bordetella pertussis. It spreads through close contact with respiratory droplets when an infected person coughs or sneezes. It is typically managed with droplet precautions, not airborne precautions.

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A nurse in the emergency department is attending to a patient exhibiting symptoms of a myocardial infarction. Which of the following actions should the nurse prioritize?

Nursing Test Bank

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