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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The nurse should respect the patient’s need for space while also expressing willingness to talk when the patient is ready.
Choice B rationale
Telling the patient “Everything will be okay” may seem dismissive of the patient’s feelings and may not be helpful in this situation.
Choice C rationale
Asking “Do you feel like crying helps?” might come across as judgmental or dismissive.
Choice D rationale
Asking “Would you like to be alone?” might make the patient feel isolated or abandoned.
Correct Answer is B
Explanation
Choice A rationale
The glomerular filtration rate (GFR) does not recover during the oliguric phase of acute kidney injury (AKI). Recovery of GFR typically occurs during the recovery phase.
Choice B rationale
During the oliguric phase of AKI, urine output is typically less than 400 mL per 24 hours.
Choice C rationale
Renal function is not reestablished during the oliguric phase of AKI. This typically occurs during the recovery phase.
Choice D rationale
Blood urea nitrogen (BUN) and creatinine levels do not decrease during the oliguric phase of AKI. These levels typically increase due to decreased kidney function.
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