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 C
Explanation
Choice A rationale:
Increased afterload refers to the resistance against which the heart must pump to eject blood into the aorta. While increased afterload can contribute to chest pain in certain conditions like aortic stenosis, it's not the primary cause of angina.
Angina is typically triggered by exertion or emotional stress, which increase myocardial oxygen demand. Increased afterload doesn't directly cause this imbalance in oxygen supply and demand, making it less likely to be the primary driver of angina pain.
Choice B rationale:
Inadequate myocardial oxygenation is a key concept in understanding angina, but it's not the most precise answer to the patient's question about the cause of their pain.
It's important to explain the underlying reason for the inadequate oxygenation, which is coronary artery disease.
Choice C rationale:
Coronary artery disease (CAD) is the most common cause of angina. It's characterized by narrowing or blockage of the coronary arteries, which supply oxygen-rich blood to the heart muscle.
When the heart's demand for oxygen exceeds the supply available through the narrowed arteries, it experiences ischemia (lack of oxygen), leading to the characteristic chest pain of angina.
This explanation directly addresses the patient's question about the cause of their pain, linking the symptom to the underlying disease process. Choice D rationale:
Increased preload refers to the amount of blood filling the ventricles before they contract. While increased preload can contribute to heart failure and pulmonary edema, it's not typically a direct cause of angina.
Correct Answer is B
Explanation
Choice A Rationale:
Repolarization is a phase in the cardiac cycle that involves the restoration of electrical charges in heart muscle cells, enabling them to prepare for the next contraction. It does not directly refer to the physical contraction and ejection of blood from the chambers.
During repolarization, the heart muscle cells regain their negative electrical charge after depolarization, which triggered the contraction.
Repolarization is essential for maintaining the heart's rhythmic electrical activity and ensuring coordinated contractions.
It does not, however, cause the chambers to become smaller and eject blood, which is the defining feature of systole.
Choice C Rationale:
Diastole is the phase of the cardiac cycle when the heart chambers relax and fill with blood. It is the opposite of systole.
During diastole, the heart muscle relaxes, allowing the chambers to passively expand and collect blood from the veins.
The atrioventricular valves (mitral and tricuspid valves) open during diastole, allowing blood to flow from the atria into the ventricles.
While diastole is crucial for ensuring adequate blood supply to the heart, it does not involve the forceful ejection of blood into circulation that characterizes systole.
Choice D Rationale:
Ejection fraction is a measurement of the heart's pumping efficiency. It represents the percentage of blood that is ejected from the left ventricle with each contraction.
A normal ejection fraction is typically between 55% and 70%.
While ejection fraction is related to systole, it is not a synonym for it. Ejection fraction is a quantitative measure of how well the heart is pumping, while systole refers to the specific phase of the cardiac cycle when contraction and ejection occur.
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