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 A
Explanation
Choice A rationale
Intermittent claudication, characterized by muscle pain during exercise relieved by rest, indicates early-stage peripheral arterial disease due to decreased blood flow. It is an early symptom resulting from insufficient oxygen supply to muscles.
Choice B rationale
Rest pain occurs in more advanced peripheral arterial disease and indicates critical limb ischemia. It is a late-stage symptom, usually present even at rest due to severely compromised blood flow.
Choice C rationale
Foot ulcers are signs of advanced peripheral arterial disease, often developing due to poor circulation and delayed wound healing. These ulcers indicate severe disease progression and significant arterial insufficiency.
Choice D rationale
Dependent rubor, a red discoloration of the skin when the leg is lowered, occurs in advanced peripheral arterial disease. It results from chronic ischemia and dilatation of the small blood vessels in response to prolonged tissue hypoxia.
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.
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