A patient is experiencing classic signs and symptoms of acute coronary artery disease.
What should be the nurse’s priority intervention?
Educate the patient about the pathophysiology causing the symptoms.
Apply supplemental Oxygen as ordered.
Administer sublingual nitroglycerin as ordered.
Remain with the patient to decrease anxiety.
The Correct Answer is C
Choice A rationale:
While educating the patient about the pathophysiology of acute coronary artery disease (ACAD) is important, it is not the priority intervention during an acute episode.
The patient is likely experiencing significant discomfort and anxiety, and their ability to process information may be impaired.
Providing immediate relief of symptoms and stabilizing the patient's condition take precedence over education at this time.
Choice B rationale:
Supplemental oxygen may be beneficial for patients with ACAD, but it is not the highest priority intervention.
Oxygen therapy can improve oxygen saturation levels in the blood, but it does not directly address the underlying issue of coronary artery occlusion.
It is important to administer nitroglycerin first to dilate the coronary arteries and improve blood flow to the heart muscle.
Choice C rationale:
Sublingual nitroglycerin is a vasodilator that relaxes and widens blood vessels, improving blood flow to the heart muscle.
It is a first-line medication for the treatment of acute angina (chest pain) and is often used in the setting of ACAD.
Nitroglycerin can rapidly relieve chest pain and other symptoms of ischemia, such as shortness of breath, and can help prevent further damage to the heart muscle.
Choice D rationale:
Staying with the patient to decrease anxiety is important, but it is not the priority intervention.
While providing emotional support can help to calm the patient and reduce stress, it does not directly address the underlying issue of myocardial ischemia.
It is crucial to administer nitroglycerin to dilate the coronary arteries and improve blood flow to the heart muscle.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice B rationale:
LDL (low-density lipoprotein) cholesterol is often referred to as "bad" cholesterol. It contributes to the buildup of plaque in the arteries, which narrows the arteries and can lead to coronary artery disease (CAD). CAD is a major risk factor for heart attack and stroke.
HDL (high-density lipoprotein) cholesterol is often referred to as "good" cholesterol. It helps to remove LDL cholesterol from the arteries and transport it back to the liver, where it can be broken down and removed from the body. Therefore, a high HDL level is protective against heart disease.
An elevated LDL level and a lowered HDL level are both associated with an increased risk of CAD. This is because the elevated LDL level contributes to plaque buildup, while the lowered HDL level means that there is less "good" cholesterol available to remove the "bad" cholesterol from the arteries.
Therefore, the statement "Increased LDL and decreased HDL increase my risk of coronary artery disease" indicates an understanding of the significance of these cholesterol levels.
Choice A rationale:
This statement is incorrect. An increased LDL level will actually increase the amount of cholesterol deposited on the artery walls.
Choice C rationale:
This statement is also incorrect. A decreased HDL level will decrease the amount of cholesterol moved away from the artery walls.
Choice D rationale:
This statement is incorrect. Increased LDL has the potential to increase, not decrease, the risk of heart disease.
Correct Answer is B
Explanation
Choice A rationale:
Sinus tachycardia is a heart rhythm characterized by a rate greater than 100 beats per minute, with normal P waves preceding each QRS complex.
It can be caused by various factors, including exercise, stress, fever, dehydration, medications, and medical conditions such as anemia, hyperthyroidism, and heart failure.
In the given rhythm, the rate is within the normal range (60-100 beats per minute), and the P waves are not clearly visible, making sinus tachycardia unlikely.
Choice B rationale:
Atrial flutter is a type of supraventricular tachycardia characterized by a rapid, regular atrial rate of around 250-350 beats per minute, with a characteristic "sawtooth" pattern on the ECG.
It is typically caused by a re-entry circuit within the atria, often involving the cavo-tricuspid isthmus.
The ventricular rate is usually slower than the atrial rate due to the atrioventricular (AV) node's inability to conduct all atrial impulses.
Atrial flutter can cause symptoms such as palpitations, shortness of breath, lightheadedness, and fatigue.
It can also lead to complications such as stroke and heart failure.
The given rhythm shows a regular atrial rate with a sawtooth pattern, consistent with atrial flutter.
Choice C rationale:
Atrial fibrillation is another type of supraventricular tachycardia characterized by rapid, irregular atrial activity with no discernible P waves on the ECG.
It is also caused by disorganized electrical activity in the atria.
The ventricular rate in atrial fibrillation is also irregular, and the rhythm is often described as "irregularly irregular." The given rhythm shows a regular atrial rate, making atrial fibrillation unlikely.
Choice D rationale:
Normal sinus rhythm is the heart's natural rhythm, characterized by a rate of 60-100 beats per minute, with normal P waves preceding each QRS complex.
The given rhythm does not have normal P waves, making normal sinus rhythm unlikely.
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