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 B

Explanation

A. “Have you experienced any nausea or vomiting with your headache?” B. “Are the lights in this room bothering you?” C. “Have you noticed any confusion or clouded thinking?” D. “Did you feel weak before the headache started or do you feel weak now?”

Correct Answer is A

Explanation

Choice A rationale

Nausea and vomiting are common symptoms associated with migraines. Asking about these symptoms can help in assessing the severity of the migraine and planning appropriate interventions.

Choice B rationale

Sensitivity to light, also known as photophobia, is a common symptom of migraines. However, the presence of this symptom alone may not provide a comprehensive understanding of the patient’s condition.

Choice C rationale

While confusion or clouded thinking can occur with migraines, they are not as common as other symptoms such as nausea, vomiting, and sensitivity to light.

Choice D rationale

Feeling weak before the headache starts or currently feeling weak can be associated with migraines, but they are not the most common symptoms.

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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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