A patient experiencing a myocardial infarction reports chest pain and shortness of breath. The first intervention should be?
Call the cardiologist
Administer oxygen
Obtain vital signs
Place the client in a supine position
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D","E"]
Explanation
A. Limiting physical activity: Sedentary behavior is a risk factor for hypertension and cardiovascular disease. Regular aerobic exercise helps lower blood pressure by improving vascular compliance and reducing systemic resistance. Clients should be encouraged to increase, rather than limit, their level of moderate physical activity.
B. Giving up smoking cigarettes: Nicotine causes immediate vasoconstriction and increases heart rate, leading to acute elevations in blood pressure. Long-term smoking damages the arterial walls and accelerates the development of atherosclerosis. Cessation is one of the most effective lifestyle changes for improving overall vascular health and reducing pressure.
C. Eating canned vegetables daily: Canned foods are typically very high in sodium, which is used as a preservative. High sodium intake leads to water retention and increased blood volume, which raises blood pressure. Clients should be advised to choose fresh or frozen vegetables to minimize their sodium consumption.
D. Pursuing measures for losing weight: Excess body weight increases the workload on the heart and is closely linked to metabolic changes that raise blood pressure. Even a modest reduction in weight can lead to a significant decrease in systolic and diastolic readings. Weight management is a cornerstone of non-pharmacological hypertension treatment.
E. Reducing sodium in the diet: High dietary salt intake triggers the body to retain fluid, increasing the total volume within the vascular system. Reducing sodium intake to less than 2,300 mg per day helps lower blood pressure and reduces the risk of stroke. This change directly addresses the fluid-volume component of hypertension.
Correct Answer is C
Explanation
A. Give 2 rescue breaths: In cardiac arrest due to V.Fib, the priority is circulation. High-quality chest compressions are initiated immediately to maintain perfusion until defibrillation can be performed. Rescue breaths are not the first step.
B. Start chest compressions: V.Fib is a lethal rhythm with no effective cardiac output. Immediate chest compressions are essential to circulate oxygenated blood to vital organs while preparing for defibrillation. This is the first action in Basic Life Support (BLS) and Advanced Cardiac Life Support (ACLS).
C. Assess the client: While assessment is important, in the context of a witnessed rhythm strip showing V.Fib and an alarm, the nurse should assume cardiac arrest and act immediately. Delaying compressions to reassess wastes critical seconds.
D. Call a code blue/call 911: This is necessary, but it comes after starting chest compressions. The priority is to begin CPR without delay, then activate emergency response and prepare for defibrillation.
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