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 C

Explanation

A) This choice is incorrect because encouraging the client to stop taking medications without consulting the healthcare provider can be dangerous, especially after an MI. Medications prescribed after an MI are essential for managing cardiovascular risks and should not be discontinued without medical advice.

B) This choice is incorrect because it is not appropriate to downplay the potential side effects of medications. While side effects may be uncommon, it is essential to provide accurate information and address the client's concerns.

C) This choice is correct. Providing information about possible side effects and instructing the client to report any adverse reactions to the healthcare provider is essential. It empowers the client to recognize and manage potential side effects appropriately, ensuring that any concerns are addressed promptly by the healthcare team.

D) This choice is incorrect because suggesting over-the-counter medications without consulting the healthcare provider can be unsafe and may interact with prescribed medications. It is essential to address side effects with the healthcare team for appropriate management and adjustments to the medication regimen if needed.

Questions

A. Diaphoresis (profuse sweating). B. Elevated blood pressure. C. Elevated body temperature. D. Bradycardia (slow heart rate).

Correct Answer is A

Explanation

A) This choice is correct. Diaphoresis (profuse sweating) is an early sign of myocardial infarction (MI) and is caused by the activation of the sympathetic nervous system in response to the heart muscle's decreased oxygen supply. Diaphoresis is often accompanied by other symptoms such as chest pain, shortness of breath, and nausea.

B) This choice is incorrect because elevated blood pressure can occur during an acute MI, but it is not an early sign of the condition.

C) This choice is incorrect because elevated body temperature is not typically associated with an MI. It may be indicative of an infection or other inflammatory conditions.

D) This choice is incorrect because bradycardia (slow heart rate) is not an early sign of an MI. Tachycardia (rapid heart rate) is more commonly associated with an acute MI as the body attempts to compensate for the decreased cardiac output.

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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 nurse is providing education to a client who recently had an MI about the importance of medication adherence. The client expresses concerns about potential side effects of the prescribed medications. What should the nurse do to address the client's concerns effectively?

Correct Answer is C

Explanation

A nurse is assessing a client with suspected myocardial infarction (MI). Which clinical manifestation should the nurse prioritize as an early sign of MI?

Correct Answer is A

Explanation

A client who had an MI is advised to quit smoking to reduce the risk of future cardiac events. The client expresses difficulty in quitting and asks the nurse for suggestions. What should the nurse recommend?

A client with suspected angina pectoris is scheduled for a coronary angiography. The client asks the nurse about the purpose of the test. How should the nurse respond?

A client with a history of angina pectoris asks the nurse about the underlying cause of the chest pain. What should the nurse explain to the client?

A client with angina pectoris is prescribed ranolazine (Ranexa) as an anti-anginal medication. What is the primary action of ranolazine in managing angina?

A client with angina pectoris reports chest pain and is receiving oxygen therapy. The client asks the nurse about the purpose of oxygen administration. How should the nurse respond?

A client who had an acute myocardial infarction (MI) is scheduled for percutaneous coronary intervention (PCI). The client asks the nurse about the purpose of this procedure. How should the nurse respond?

A client with acute myocardial infarction (MI) is prescribed aspirin. The client asks the nurse about the purpose of this medication. How should the nurse respond?

A client with angina pectoris is receiving sublingual nitroglycerin for chest pain relief. After administering the medication, what should the nurse instruct the client to do?