A nurse is assessing a patient with chest pain. Which action is most appropriate to determine if the patient is experiencing a myocardial infarction?
Perform a 12 lead EKG
Check the patient's blood pressure
Auscultate the patient's heart sounds
Determine is the pain radiates to the left arm
The Correct Answer is A
A. Perform a 12 lead EKG – A 12-lead electrocardiogram (EKG/ECG) is the most appropriate and immediate diagnostic tool to assess for myocardial infarction (MI). It can detect ST segment changes, T wave inversions, or Q waves that indicate ischemia or infarction.
B. Check the patient's blood pressure – While important for overall assessment, blood pressure alone cannot confirm or rule out an MI.
C. Auscultate the patient's heart sounds – This may reveal abnormalities (e.g., S3, murmurs), but it is not diagnostic for MI.
D. Determine if the pain radiates to the left arm – Radiation of pain is a classic symptom of MI, but it is subjective and not sufficient to confirm the diagnosis without further diagnostic tests like an EKG.
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Related Questions
Correct Answer is C
Explanation
A. The client has become addicted to the medication. – Addiction involves compulsive drug-seeking behavior and use despite harm. In a hospice setting, tolerance and dependence are expected and should not be confused with addiction.
B. The client is experiencing episodes of confusion. – While morphine may cause confusion, especially in elderly or very ill clients, this does not explain the need for a higher dose for pain relief.
C. The client developed a tolerance to the medication. – Tolerance occurs when the body becomes accustomed to a drug, requiring higher doses to achieve the same effect. This is common with long-term opioid use for chronic or terminal pain.
D. The client has not been taking the medication properly. – There is no indication of noncompliance. The need for a higher dose is more accurately attributed to tolerance, especially in terminal illness.
Correct Answer is D
Explanation
A. Document that the client experienced an anaphylactic reaction to the medication. – The symptoms described (flushing and tachycardia) are more indicative of Red Man Syndrome, a rate-related infusion reaction, not an anaphylactic allergic response.
B. Change the IV infusion site. – There’s no indication of infiltration or phlebitis at the IV site. The issue is related to infusion speed, not the site.
C. Apply cold compresses to the neck area. – Cold compresses will not address the systemic reaction caused by rapid vancomycin infusion.
D. Decrease the infusion rate on the IV. – Flushing of the neck and upper body with tachycardia suggests Red Man Syndrome, a common reaction to rapid infusion of vancomycin. The appropriate action is to slow the infusion rate, which often resolves the symptoms.
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