A nurse is caring for a client admitted with myocardial infarction (MI). The client's blood pressure drops, and the client becomes restless and anxious. What intervention should the nurse initiate first?
Administer oxygen therapy.
Elevate the client's legs.
Obtain a 12-lead electrocardiogram (ECG).
Initiate cardiopulmonary resuscitation (CPR).
The Correct Answer is A
A) This choice is correct. Administering oxygen therapy is the priority intervention when a client with MI experiences a drop in blood pressure and becomes restless and anxious. Oxygen can improve tissue oxygenation and help stabilize the client's condition.
B) This choice is incorrect because elevating the client's legs may be beneficial in certain situations, but it is not the priority when the client is experiencing a drop in blood pressure and restlessness due to MI.
C) This choice is incorrect because obtaining a 12-lead ECG is important for assessing and diagnosing MI, but it is not the priority when the client's condition is deteriorating rapidly.
D) This choice is incorrect because initiating cardiopulmonary resuscitation (CPR) is not indicated in this scenario. The client is still conscious and experiencing symptoms, indicating a need for prompt oxygen administration and further assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) This choice is incorrect because chest pain caused by an irregular heart rhythm is more characteristic of arrhythmias, not angina pectoris.
B) This choice is correct. Angina pectoris is caused by the narrowing of the coronary arteries due to atherosclerotic plaques, leading to reduced blood flow to the heart muscle during periods of increased demand (e.g., physical exertion, stress).
C) This choice is incorrect because inflammation in the lining of the heart is associated with conditions like pericarditis or myocarditis, not angina pectoris.
D) This choice is incorrect because chest pain caused by the heart muscle overworking is more typical of conditions like heart failure, not angina pectoris.
Correct Answer is D
Explanation
A: This choice is incorrect because nitroglycerin tablets should not be swallowed immediately; they are designed to dissolve under the tongue to provide rapid relief from chest pain.
B: This choice is incorrect as nitroglycerin tablets do not need to be taken with water; they should dissolve sublingually and taking them with water could dilute the medication, reducing its effectiveness.
C: This choice is incorrect because crushing the tablet and mixing it with food would delay and potentially reduce the absorption of the medication, which is critical during an episode of angina.
D: This is the correct instruction because nitroglycerin tablets are very sensitive to light and moisture, which can reduce their effectiveness. Keeping them in their original bottle ensures they are protected from environmental factors that could degrade the medication.
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