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: While attaching leads for a 12-lead ECG is important, it is not the most immediate action required for a client showing signs of distress and potential hypoxia.

Choice B reason: Obtaining a blood sample is necessary for diagnosing the cause of chest pain but is not the first priority in an emergency situation.

Choice C reason: Initiating oxygen therapy is the first and most critical step in managing a client with severe chest pain, shortness of breath, and cyanosis to ensure adequate oxygenation.

Choice D reason: Inserting an IV catheter is important for administering medications and fluids but comes after ensuring the client is receiving sufficient oxygen.

A. Your heart stops. B. Your heart is pumping too much blood. C. Your heart has an area of muscle that has died. D. Your heart is not an efficient pump.

Correct Answer is D

Explanation

Choice A reason: The statement "Your heart stops" is incorrect; heart failure does not mean the heart has stopped functioning.

Choice B reason: "Your heart is pumping too much blood" is not accurate; heart failure often means the heart cannot pump enough blood to meet the body's needs.

Choice C reason: While an area of heart muscle may die during a heart attack, this is not the defining characteristic of heart failure.

Choice D reason: The most accurate description of heart failure is that the heart is not pumping efficiently, which can lead to symptoms like fatigue and shortness of breath.

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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?

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A patient asks the nurse what a diagnosis of heart failure means. Which of the following is the nurse's best response?

Correct Answer is D

Explanation

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