A nurse on a medical-surgical unit is caring for a client who reports pain in the jaw, back, and shoulder, shortness of breath, and nausea.
Which of the following actions should the nurse take?
Administer ibuprofen.
Administer enteric-coated acetaminophen.
Maintain oxygen saturation greater than or equal to 92%.
Obtain an EKG.
The Correct Answer is D
Choice A rationale
Ibuprofen is not indicated for chest pain that may suggest myocardial infarction (MI). NSAIDs like ibuprofen can increase cardiovascular risk, thus inappropriate for suspected cardiac events. Administering ibuprofen could mask symptoms.
Choice B rationale
Enteric-coated acetaminophen is not suitable for acute chest pain related to suspected MI. It offers pain relief but does not address underlying ischemic heart disease. Immediate cardiac evaluation and intervention are required in such cases.
Choice C rationale
While maintaining oxygen saturation is essential, it does not address the need for immediate cardiac evaluation in suspected MI. Adequate oxygenation supports tissue perfusion, but it is not the definitive diagnostic or therapeutic intervention.
Choice D rationale
Obtaining an EKG is crucial for diagnosing myocardial infarction by assessing electrical activity of the heart. It helps identify ischemia or infarction. Early detection of abnormalities ensures prompt treatment and reduces complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
A red and beefy tongue suggests nutritional deficiencies like iron or vitamin B12 deficiency, not digoxin toxicity.
Choice B rationale
Constipation is a gastrointestinal issue, commonly related to diet, fluid intake, or other medications, not an indicator of digoxin toxicity.
Choice C rationale
Digoxin toxicity often manifests as visual disturbances, such as yellow or blurred vision, due to its effect on the central nervous system.
Choice D rationale
Weight gain is not associated with digoxin toxicity but may result from other conditions such as hypothyroidism or fluid retention.
Correct Answer is A
Explanation
Choice A rationale
The first upward deflection in an ECG represents the P wave, indicating atrial depolarization. It precedes the QRS complex and corresponds to the electrical activity associated with atrial contraction, initiating the cardiac cycle.
Choice B rationale
The peak of the first wave corresponds to the R wave, not the P wave. The R wave is a part of the QRS complex, representing ventricular depolarization, and is not associated with atrial depolarization.
Choice C rationale
The downward deflection following the peak is the S wave, part of the QRS complex, indicating ventricular depolarization. It is not related to the P wave, which specifically represents atrial depolarization.
Choice D rationale
The second upward deflection is the T wave, which represents ventricular repolarization. It follows the QRS complex and is not associated with atrial depolarization or the P wave.
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