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A patient experiencing a myocardial infarction reports chest pain and shortness of breath. The first intervention should be?

A.

Call the cardiologist

B.

Administer oxygen

C.

Obtain vital signs

D.

Place the client in a supine position

Answer and Explanation

The Correct Answer is B

A. Call the cardiologist: Contacting the specialist is necessary for definitive management but is not the most immediate nursing action. Delays in providing basic physiological support while waiting for a physician's response can lead to further myocardial damage. Initial stabilization must occur before coordinating the next level of specialized care.

B. Administer oxygen: Myocardial infarction involves a critical mismatch between oxygen supply and demand in the cardiac tissue. Providing supplemental oxygen increases the concentration of oxygen in the blood to help salvage ischemic myocardium and relieve dyspnea. This is a primary intervention to reduce the severity of the infarct and stabilize the patient.

C. Obtain vital signs: While baseline data is important for monitoring, the patient's immediate report of shortness of breath indicates an acute respiratory and circulatory crisis. Taking blood pressure and temperature does not actively treat the underlying hypoxia or chest pain. Interventions to improve oxygenation should take precedence over data collection during active ischemia.

D. Place the client in a supine position: Lying flat increases venous return and the workload of the heart, which can worsen both chest pain and shortness of breath. Patients in respiratory distress should be placed in a high-Fowler's position to maximize lung expansion and decrease cardiac strain. A supine position is physiologically detrimental during an acute coronary event.


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Related Questions

Correct Answer is A

Explanation

A. Obtain manual blood pressure: Assessing the hemodynamic status is the priority when a client reports a racing heartbeat and shortness of breath. An irregular rhythm following conversion of atrial fibrillation requires immediate validation of perfusion and blood pressure stability. Manual measurement provides the most accurate clinical data for determining the severity of the cardiovascular change.

B. Measure airflow via incentive spirometry: Incentive spirometry is used to prevent atelectasis and is not a diagnostic tool for acute shortness of breath or cardiac arrhythmias. It does not provide information regarding the underlying cause of the "racing heartbeat" or the irregular rhythm. Priority must be placed on cardiovascular assessment rather than routine respiratory exercises.

C. Insert indwelling urinary catheter: There is no immediate clinical indication for an invasive urinary catheter based on the client's current symptoms of palpitations and dyspnea. While monitoring output is important in heart failure, it is secondary to stabilizing the client's heart rate and rhythm. Catheterization poses an unnecessary infection risk in this acute assessment phase.

D. Assist the patient to get dressed to work with physical therapy: Engaging in physical exertion while experiencing tachycardia and shortness of breath is dangerous and contraindicated. The client's reports of a "racing heartbeat" and irregular rhythm indicate a potential relapse into atrial fibrillation with rapid response. Physical activity should be deferred until the client is hemodynamically stable.

Correct Answer is C

Explanation

A. Assessing the legs and feet for peripheral edema: While edema is an important indicator of heart failure, it does not provide real-time information about the electrical activity of the heart. Edema is a chronic sign of volume overload rather than an acute indicator of dysrhythmia severity. It is not the most critical assessment prior to antiarrhythmic administration.

B. Checking the results of the most recent ECG: An ECG provides a snapshot of previous electrical activity but may not reflect the patient's current hemodynamic status. The nurse must assess the patient's actual physiological presentation at the moment the medication is being given. Bedside assessment is superior to relying solely on historical diagnostic data.

C. Listening to the apical pulse for a full minute: Antiarrhythmic medications can significantly alter heart rate and rhythm, potentially causing profound bradycardia or new conduction blocks. Assessing the apical pulse for 60 seconds provides the most accurate baseline of the heart's current rate and regularity. This is a mandatory safety step to ensure the patient can tolerate the drug.

D. Taking the blood pressure in both arms: While blood pressure is a vital sign, it is a secondary manifestation of the heart's pumping efficiency rather than a direct measure of the rhythm. A single arm reading is usually sufficient unless a specific vascular discrepancy is suspected. The primary concern with dysrhythmia medications is the heart rate itself.

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