A nurse in the emergency room is caring for a client who presents with manifestations that indicate a myocardial infarction. Which of the following prescriptions should the nurse take first?

Attach the leads for a 12-lead ECG.

Initiate oxygen therapy.

Insert the IV catheter.

Obtain a blood sample.

Answer and Explanation

The Correct Answer is B

The correct answer is: B. Initiate oxygen therapy.

Choice A reason:

Attaching the leads for a 12-lead ECG is crucial for diagnosing a myocardial infarction. However, it is not the first priority. Ensuring the patient receives adequate oxygen is more critical to prevent further myocardial damage. The ECG can be performed immediately after oxygen therapy is initiated to confirm the diagnosis and guide further treatment.

Choice B reason:

Initiating oxygen therapy is the first priority because it ensures that the heart muscle receives adequate oxygen, which is essential to prevent further damage during a myocardial infarction. Oxygen therapy helps to maintain tissue oxygenation and can reduce the extent of myocardial injury. This immediate intervention is vital to stabilize the patient and improve outcomes.

Choice C reason:

Inserting the IV catheter is important for administering medications and fluids. However, it is not the first step. Oxygen therapy takes precedence to ensure the heart and other vital organs receive sufficient oxygen. Once oxygen is administered, IV access can be established to facilitate further treatment.

Choice D reason:

Obtaining a blood sample is necessary for confirming the diagnosis and assessing cardiac markers. However, it is not the immediate priority. Ensuring the patient is oxygenated is more urgent to prevent further myocardial damage. Blood samples can be drawn after oxygen therapy is initiated.

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Correct Answer is B

Explanation

Choice A Reason: This is incorrect because a decreased level of consciousness is a late sign of shock, not an early one. Decreased level of consciousness indicates that the brain is not receiving enough oxygen and blood ﬂow, which can lead to irreversible damage and death.

Choice B Reason: This is correct because increased respiratory rate is an early sign of shock, indicating hypoxia. This finding indicates that the client is experiencing hypoxia, which is a lack of oxygen in the tissues and organs. Hypoxia is a common and early sign of shock, which is a condition where the body's vital organs do not receive enough blood

ﬂow and oxygen due to low blood pressure, low cardiac output, or low blood volume. The client's respiratory rate increases as a compensatory mechanism to increase oxygen intake and delivery.

Choice C Reason: This is incorrect because hypotension is a late sign of shock, not an early one. Hypotension indicates that the blood pressure is too low to maintain adequate perfusion and oxygenation to the vital organs.

Choice D Reason: This is incorrect because anuria is a late sign of shock, not an early one. Anuria indicates that the kidneys are not receiving enough blood ﬂow and oxygen, which can result in acute kidney injury or failure.

A. Administer opioids. B. Darken the room. C. Apply restraints. D. Reduce stimuli.

Correct Answer is D

Explanation

Choice A Reason: This is incorrect. Opioids are not indicated for a client who is emerging from a coma, as they can cause respiratory depression, sedation, and confusion. They may also mask the signs of increased intracranial pressure or neurological deterioration.

Choice B Reason: This is incorrect. Darkening the room may not be helpful for a client who is emerging from a coma, as it may increase their disorientation and agitation. The nurse should provide adequate lighting and orient the client to time, place, and person frequently.

Choice C Reason: This is incorrect. Applying restraints may worsen the restlessness and agitation of a client who is emerging from a coma, as they may perceive them as a threat or a restriction. Restraints may also increase the risk of injury, infection, or skin breakdown. The nurse should use restraints only as a last resort and with a physician's order.

Choice D Reason: This is correct. Reducing stimuli is an appropriate intervention for a client who is emerging from a coma, as it can help calm them and prevent sensory overload. The nurse should limit noise, visitors, and unnecessary procedures, and provide a quiet and comfortable environment.

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A nurse in the emergency room is caring for a client who presents with manifestations that indicate a myocardial infarction. Which of the following prescriptions should the nurse take first?

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