Exhibits
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
The Correct Answer is []
- Myocardial infarction (MI) is suggested by chest pain radiating to the left arm, diaphoresis, shortness of breath, and epigastric discomfort. The pain described as "sharp, tight, and like indigestion" aligns with cardiac ischemia.
- Administering oxygen helps improve myocardial oxygenation, reducing ischemia.
- Aspirin 325 mg is a standard intervention in suspected MI to prevent further platelet aggregation and reduce the risk of worsening thrombosis in the coronary arteries.
- Monitoring vital signs is critical to assess for hemodynamic stability and signs of worsening cardiac function (e.g., hypotension, tachycardia).
- Monitoring ECG rhythm helps detect ST-elevation or other ischemic changes and assess for life-threatening arrhythmias.
- Morphine may be used for chest pain, but it is now considered secondary to nitroglycerin and beta-blockers.
- Verapamil is a calcium channel blocker used for rate control in arrhythmias but is not first-line for acute MI.
- Platelet count and WBC count are not immediately relevant to MI management.
- Serum glucose levels may be affected by stress but are not a primary concern in acute MI management.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. First-degree heart block has a regular R-R interval, meaning the rhythm is typically regular.
B. The presence of P waves is a distinguishing feature of first-degree heart block. Absent P waves are more characteristic of atrial fibrillation or junctional rhythms.
C. First-degree heart block is characterized by a prolonged PR interval greater than 0.20 seconds, but all impulses are still conducted to the ventricles.
D. A progressively lengthening PR interval followed by a dropped QRS complex is indicative of second-degree Mobitz Type I (Wenckebach) heart block, not first-degree heart block.
Correct Answer is B
Explanation
A. Pruritus is not a common side effect of heparin therapy. While allergic reactions can occur, they are not the primary concern.
B. Petechiae are a sign of bleeding, which is a major side effect of heparin therapy. Heparin increases the risk of bleeding by inhibiting clot formation, and petechiae may indicate early signs of hemorrhage.
C. Confusion is not directly associated with heparin therapy unless it results from severe bleeding leading to hypoxia or shock.
D. A slowing pulse rate is not a known adverse effect of heparin. Instead, monitoring for signs of bleeding, such as bruising, hematuria, and petechiae, is the priority.
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