A nurse is caring for a patient who has a suspected myocardial infarction. Which of the following should the nurse administer first?

Nitroglycerin

Aspirin

Morphine

Oxygen

Answer and Explanation

The Correct Answer is D

A. Nitroglycerin: Nitroglycerin is used to relieve chest pain by dilating coronary arteries and increasing blood flow. However, in the immediate setting of a suspected MI, oxygen is prioritized to ensure adequate oxygenation.

B. Aspirin: Aspirin is essential in the early treatment of MI to prevent further clot formation by inhibiting platelet aggregation, but oxygen would still come first if the client’s oxygenation is compromised.

C. Morphine: Morphine is used for pain relief and to reduce anxiety and oxygen demand on the heart. However, it is administered after ensuring oxygen supply.

D. Oxygen: Oxygen should be administered first in a suspected myocardial infarction to ensure the heart and tissues receive adequate oxygen, especially if the patient is hypoxic.

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Correct Answer is C

Explanation

A. Obtain platelet aggregation studies to confirm DVT. Platelet aggregation studies are not used to diagnose deep vein thrombosis (DVT). They are more relevant for evaluating platelet function and clotting disorders.

B. Schedule deep tissue massage with physical therapy. Deep tissue massage is contraindicated in clients suspected of having DVT, as it could dislodge the clot and cause a pulmonary embolism or other complications.

C. Arrange for a venous duplex ultrasound. A venous duplex ultrasound is the standard diagnostic test used to confirm DVT. It visualizes the veins and assesses blood flow, helping to detect the presence of a clot.

D. Monitor Homan's sign. Homan’s sign (pain in the calf with dorsiflexion of the foot) was once considered a diagnostic indicator of DVT, but it is no longer considered reliable due to its low sensitivity and specificity. Therefore, it is not routinely used for DVT diagnosis.

A. "You will be prescribed medication that will keep you well for years to come." B. "Do you have family members who died from heart disease?" C. "You should discuss these worries with your physician." D. "Tell me more about these fears."

Correct Answer is D

Explanation

A. "You will be prescribed medication that will keep you well for years to come." This response provides false reassurance. Although medications can help manage angina, it does not guarantee that the client will not experience future complications.

B. "Do you have family members who died from heart disease?" This question may not address the client's immediate emotional needs and could come off as dismissive of the client's fear.

C. "You should discuss these worries with your physician." This statement redirects the client's concerns to the physician rather than addressing the client's emotional needs and fears in the moment.

D. "Tell me more about these fears." This response is therapeutic and encourages the client to express his concerns and feelings, which is a key part of addressing fear and anxiety.

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A nurse is caring for a patient who has a suspected myocardial infarction. Which of the following should the nurse administer first?

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