A patient hospitalized with a myocardial infarction suddenly begins having severe respiratory distress with frothy red sputum. What is the first action for the nurse to take?

Notify the patient's family.

Provide oxygen as prescribed.

Notify the health care provider.

Elevate the head of the bed.

Answer and Explanation

The Correct Answer is B

Choice A Reason:Notifying the patient's family is not the immediate priority when the patient is experiencing severe respiratory distress. The nurse's primary focus should be on addressing the patient's acute symptoms.

Choice B Reason:Providing oxygen is crucial in managing respiratory distress. In a patient with myocardial infarction (heart attack), adequate oxygenation is essential to prevent further complications. The nurse should promptly administer oxygen as prescribed to improve oxygen supply and alleviate distress.

Choice C Reason:While notifying the health care provider is essential, it is not the first action in this critical situation. The nurse should prioritize interventions that directly address the patient's distress.

Choice D Reason:Elevating the head of the bed (semi-Fowler's position) is beneficial for patients with respiratory distress, but it is not the initial action. Providing oxygen takes precedence over positioning.

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Correct Answer is C

Explanation

Choice A reason: Electroconvulsive therapy (ECT) requires informed consent, as it is a significant medical procedure involving anesthesia and induced seizures. Informed consent is a process where a patient is fully informed about the procedures and risks involved in a treatment and voluntarily agrees to it.

Choice B reason: Nurses cannot share information with a client's family without the client's permission due to confidentiality laws, except in specific circumstances defined by law. Patient information is protected under the Health Insurance Portability and Accountability Act (HIPAA), which requires patient consent for disclosure.

Choice C reason: Patients have the right to refuse medication. This right is part of the patient's autonomy and informed consent process. A mentally competent adult can refuse treatment, even if it may result in serious illness or death.

Choice D reason: The use of restraints in mental health facilities is highly regulated. Restraints may only be used when necessary to prevent immediate harm to the patient or others and must be discontinued as soon as the risk of harm has subsided.

A. The pain worsens with deep inspiration. B. The pain persists with rest and organic nitrates. C. Exertion and anxiety can trigger the pain. D. The pain usually lasts more than 20 minutes.

Correct Answer is C

Explanation

Choice A reason: Anginal pain typically does not worsen with deep inspiration; this is more characteristic of pleuritic chest pain.

Choice B reason: Anginal pain usually does not persist with rest and organic nitrates; these interventions are typically used to alleviate angina.

Choice C reason: Exertion and anxiety increase the heart's demand for oxygen, which can trigger anginal pain due to reduced blood flow in narrowed coronary arteries.

Choice D reason: Anginal pain typically lasts for a short time, usually less than 20 minutes. If the pain lasts longer, it may indicate a more serious condition like a myocardial infarction.

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A patient hospitalized with a myocardial infarction suddenly begins having severe respiratory distress with frothy red sputum. What is the first action for the nurse to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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