A nurse is caring for a client who reports a new onset of severe chest pain. Which of the following actions should the nurse take to determine if the client is experiencing a myocardial infarction?
Perform a 12-lead ECG
Determine if pain radiates to the left arm
Check the client's blood pressure
Auscultate heart tones
The Correct Answer is A
Choice A reason: A 12-lead ECG can reveal changes in the ST segment, T wave, and QRS complex, which are indicative of myocardial ischemia, injury, or infarction. It is the first line diagnostic test that needs to be recorded within 10 minutes after the first medical contact in cases of suspected acute coronary syndromes.
Choice B reason: While pain radiating to the left arm can be a symptom of MI, it is not a definitive diagnostic action. It is a common symptom but can also be associated with other conditions.
Choice C reason: Checking the client's blood pressure is important in the overall assessment of the client's cardiovascular status but does not specifically diagnose MI. Blood pressure can be normal, elevated, or decreased in the case of MI.
Choice D reason: Auscultating heart tones can provide information about the presence of murmurs, gallops, or rubs, but it is not a specific diagnostic action for MI. Heart sounds may be normal during an MI.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["35"]
Explanation
- Step 1: Identify the total volume to be administered. The nurse is scheduled to administer 840 mL of enteral nutrition over a 24-hour period.
- Step 2: Identify the total time over which the volume is to be administered. The total time is 24 hours.
- Step 3: Calculate the rate at which the infusion pump should be set. We can do this by dividing the total volume by the total time:
- Rate = Total Volume ÷ Total Time.
- Rate = 840 mL ÷ 24 hours.
- Calculating the division gives us: Rate = 35 mL/hr.
set the infusion pump to deliver 35 mL/hr.
Correct Answer is ["A","B","C","D","F"]
Explanation
Choice A: Administer antiemetics as needed Reason: Acute pancreatitis often causes severe nausea and vomiting. Antiemetics are administered to control these symptoms and prevent further complications such as dehydration and electrolyte imbalance.
Choice B: Administer analgesics as needed Reason: Pain management is a crucial part of the treatment for acute pancreatitis. The condition can cause severe abdominal pain, and analgesics are administered to provide relief.
Choice C: NPO (nothing by mouth) until pain-free Reason: The goal in treating acute pancreatitis is to allow the pancreas to rest and recover from the inflammation3. Keeping the patient NPO (nothing by mouth) helps achieve this by reducing the stimulation and workload of the pancreas.
Choice D: Monitor blood glucose and provide insulin as needed Reason: Acute pancreatitis can affect the pancreas’ ability to produce insulin, leading to elevated blood glucose levels. Therefore, monitoring blood glucose levels and administering insulin as needed is an important part of the management plan.
Choice E: Side-lying or fetal position Reason: While the side-lying or fetal position might help some patients with abdominal pain, it is not a standard intervention for acute pancreatitis. Therefore, this option is not correct.
Choice F: Monitor hydration status Reason: Patients with acute pancreatitis are at risk of dehydration due to symptoms like vomiting and decreased oral intake. Monitoring hydration status is crucial to ensure appropriate fluid replacement.
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