A nurse is caring for a client experiencing chest pain and suspecting myocardial infarction (MI). What is the priority nursing intervention during the initial assessment?

Administering sublingual nitroglycerin.

Obtaining a 12-lead electrocardiogram (ECG).

Initiating intravenous (IV) access.

Administering aspirin.

Answer and Explanation

The Correct Answer is B

A) This choice is incorrect because administering sublingual nitroglycerin is an important intervention to relieve chest pain in clients with angina pectoris, but obtaining a 12-lead ECG is the priority in a client suspected of experiencing an MI. The ECG helps in diagnosing MI and determining the appropriate treatment plan.

B) This choice is correct. The priority nursing intervention during the initial assessment of a client with suspected MI is to obtain a 12-lead ECG. The ECG provides crucial information about cardiac electrical activity and helps identify ST-segment elevation, indicating myocardial ischemia or injury.

C) This choice is incorrect because initiating intravenous (IV) access is an essential step in the management of an MI, but it is not the priority over obtaining a 12-lead ECG.

D) This choice is incorrect because administering aspirin is an essential intervention during an MI to help reduce platelet aggregation and prevent further clot formation. However, obtaining a 12-lead ECG takes precedence in the initial assessment to confirm the diagnosis and guide further interventions.

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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.

A. "Exercise will help you lose weight and reduce your risk of developing diabetes." B. "It improves blood flow to your heart and can help lower your blood pressure." C. "Exercise is primarily for building muscle strength and improving bone health." D. "It helps you cope with stress and anxiety related to your heart condition."

Correct Answer is B

Explanation

A) This choice is incorrect because while exercise can contribute to weight loss and reduce the risk of diabetes, its primary benefit in cardiac rehabilitation is related to cardiovascular health, specifically improving blood flow to the heart and lowering blood pressure.

B) This choice is correct. Regular exercise in cardiac rehabilitation has significant benefits for the cardiovascular system. It improves blood flow to the heart muscle, enhances collateral circulation, and can help lower blood pressure, all of which are crucial in managing and preventing further complications after an MI.

C) This choice is incorrect because although exercise can help build muscle strength and improve bone health, these are not the primary benefits sought in cardiac rehabilitation. The focus is on cardiovascular health and recovery.

D) This choice is incorrect because while exercise can have positive effects on mental health, such as reducing stress and anxiety, its primary benefit in cardiac rehabilitation is related to cardiovascular health.

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A nurse is caring for a client experiencing chest pain and suspecting myocardial infarction (MI). What is the priority nursing intervention during the initial assessment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with angina pectoris is prescribed sublingual nitroglycerin tablets. What instructions should the nurse provide about taking nitroglycerin?

Correct Answer is D

Explanation

A client who recently had an MI is instructed to participate in cardiac rehabilitation. The client asks the nurse about the benefits of exercise in the program. How should the nurse respond?

Correct Answer is B

Explanation

A nurse is providing education to a client with angina about stress management techniques. The client asks the nurse how stress affects the heart. How should the nurse respond?

A client is admitted with chest pain, and the nurse suspects angina pectoris. Which diagnostic test would the nurse expect to be ordered as an initial assessment?

A nurse is educating a group of clients about the risk factors for myocardial infarction (MI). Which risk factor is considered a non-modifiable risk factor for MI?

A client with angina pectoris complains of chest pain after walking up a flight of stairs. What nursing action is the priority during this angina episode?

A nurse is providing education to a client who recently had an MI about dietary changes to improve heart health. The nurse advises the client to limit intake of saturated fats. Which food choices should the client avoid to comply with this recommendation?

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?

A nurse is caring for a client admitted with chest pain, and the healthcare provider orders a cardiac biomarker test. Which biomarker is most specific for diagnosing a myocardial infarction (MI)?

A client comes to the emergency department with chest pain, and the nurse suspects a myocardial infarction (MI). What is the priority action for the nurse?