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A nurse is caring for a client in the emergency department (ED). The client presents with substernal chest pain that comes and goes.

  • The client states that the pain has been occurring for the last 6 hours.
  • The pain, at times, radiates down the left arm.
  • The client also reports intermittent nausea.
  • The client appears pale and slightly diaphoretic.
  • The client rates current pain as 8 on a scale of 0 to 10. The nurse is planning care for the client.

For each potential prescription, indicate whether it is indicated, nonessential, or contraindicated.

A.

Administer oxygen to maintain oxygen saturation greater than 94%.

B.

Prepare the client for intubation.

C.

Apply continuous ECG monitoring.

D.

Obtain the client’s family history.

Answer and Explanation

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

Choice A - Indicated:

  • Administering oxygen to maintain oxygen saturation >94% is recommended in suspected acute coronary syndrome (ACS) to prevent myocardial hypoxia.
  • Oxygen therapy is not routinely given if SpO₂ is ≥94%, but if there are signs of hypoxia, respiratory distress, or low saturation, it is appropriate.

Choice B - Contraindicated:

  • Intubation is not indicated unless the patient has severe respiratory distress or impending respiratory failure.
  • This client is not in respiratory failure (no severe dyspnea, altered consciousness, or worsening hypoxia).

Choice C - Indicated:

  • Continuous ECG monitoring is essential in suspected ACS to detect arrhythmias, ischemia, and ST changes.
  • ECG findings will guide early intervention, including medication administration (e.g., aspirin, nitroglycerin) or reperfusion therapy.

Choice D - Nonessential:

  • Family history of cardiovascular disease is important for risk assessment but is not a priority in an acute setting.
  • While it can help with long-term management, immediate interventions (oxygen, ECG, medications) take precedence.


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Related Questions

Correct Answer is B

Explanation

Choice A rationale

Aspirin's antipyretic action reduces fever by inhibiting prostaglandin synthesis in the hypothalamus, but this is not the primary rationale for post-MI use. Normal body temperature: 36.5-37.5°C.

Choice B rationale

Aspirin acts as an antiplatelet agent by irreversibly inhibiting cyclooxygenase-1 (COX-1) enzyme, reducing thromboxane A2 production, thereby preventing platelet aggregation and thrombus formation. This helps reduce MI risk.

Choice C rationale

As an analgesic, aspirin inhibits COX enzymes, reducing prostaglandin synthesis and alleviating pain, but this is not the primary reason for its use in MI patients. Pain relief is a secondary benefit.

Choice D rationale

Aspirin's anti-inflammatory properties result from inhibiting COX enzymes and reducing prostaglandin synthesis, but this effect is not the primary rationale for its use post-MI. It helps but is not the main goal.

Correct Answer is D

Explanation

Choice A rationale

Flushed, warm legs are characteristic of chronic venous insufficiency, not peripheral artery disease, which results in poor arterial blood flow and cool extremities.

Choice B rationale

Thin, pliable toenails suggest nutritional deficiencies or fungal infections, not advanced peripheral artery disease, which often leads to thick, brittle nails.

Choice C rationale

Hairy legs are indicative of adequate blood flow. In peripheral artery disease, decreased blood flow results in hair loss on the legs.

Choice D rationale

Leg pain at rest, called rest pain, signifies advanced peripheral artery disease due to severe arterial insufficiency and poor oxygen supply to tissues. .

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