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A nurse is caring for a client in the emergency department (ED).

<div id="exhibits">Exhibits</div>

The nurse is planning care for the client. For each potential prescription, indicate whether it is an anticipated (high priority), nonessential (low priority), contraindicated(unrelated).

Select one or more in each option.

A.

Administer furosemide IV

B.

Prepare the client for intubation

C.

Obtain the client’s full family history

D.

Administer O2 to maintain oxygen saturation greater than 90%

E.

Apply continuous ECG monitoring

F.

Obtain vascular access

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"C"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"}}

Administer furosemide IV: Furosemide is a diuretic used to manage fluid overload, which is not the primary concern in this scenario. The client presents with chest pain suggestive of a cardiac event, so other interventions should take priority.

Prepare the client for intubation: Intubation is not indicated at this stage as the patient is conscious, has a respiratory rate of 18/min, and there is no immediate indication of airway compromise. Oxygen therapy is more appropriate.

Obtain the client’s full family history: While obtaining a full family history is important for a comprehensive assessment, it is not a high priority in the acute management of this client who presents with symptoms suggestive of a myocardial infarction (MI).

Administer O2 to maintain oxygen saturation greater than 90%: The client’s oxygen saturation is 88%, which is below the desired level. Administering oxygen to maintain saturation greater than 90% is a high-priority intervention to improve oxygenation.

Apply continuous ECG monitoring: Continuous ECG monitoring is essential in this scenario to monitor for arrhythmias and assess for ongoing ischemia, given the client’s chest pain, irregular pulse, and the high likelihood of an acute coronary syndrome.

Obtain vascular access: Establishing vascular access is a high priority to ensure the ability to administer medications, fluids, and for potential blood draws, especially in an emergency setting where rapid intervention may be necessary.


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Related Questions

Correct Answer is A

Explanation

A. Sudden weight gain can indicate fluid retention, a common early sign of heart failure exacerbation. Prompt reporting allows for early intervention.

B. Nitroglycerin is used to treat chest pain, not specifically to prevent heart failure exacerbations.

C. Assessment of the apical pulse is important, but monitoring weight is more directly related to managing heart failure.

D. Compliance with diuretic therapy is important, but recognizing early signs of fluid retention, such as rapid weight gain, is crucial for preventing exacerbations.

Correct Answer is C

Explanation

A. A depressed ST-segment is often associated with ischemia or non-ST elevation myocardial infarction (NSTEMI), not an ongoing MI.

B. A depressed ST-segment with normal cardiac enzymes suggests ischemia rather than an active MI.

C. ST-segment elevation on ECG combined with elevated cardiac biomarkers such as CK-MB or troponin levels is a hallmark of an acute ST-segment elevation myocardial infarction (STEMI), indicating an ongoing MI.

D. A Q wave on ECG indicates an old infarction and is not associated with an acute MI if enzymes and troponin levels are normal.

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