Exhibits
The nurse reviews chart data.
Complete the diagram by dragging from the choices area which potential condition the client is experiencing, two actions to take, and two parameters the nurse would monitor.
The Correct Answer is []
- Myocardial infarction (MI): The client reports chest pain rated 8/10, radiating to the left arm, and has ST segment elevation on ECG. These findings are classic for ST-elevation myocardial infarction (STEMI), requiring immediate intervention.
- Draw laboratory cardiac markers: Troponin and other cardiac enzymes are critical for confirming myocardial injury. They help guide diagnosis, treatment, and monitoring of MI progression or resolution.
- Insert two peripheral IV (PIV) access devices: Dual IV access ensures reliable and rapid administration of emergency medications, fluids, or thrombolytics. This is vital for stabilizing the client during acute cardiac events.
- Pain level: Ongoing pain assessment is essential for monitoring myocardial ischemia, evaluating treatment response, and guiding further interventions to prevent cardiac tissue damage.
- 12-lead electrocardiogram (ECG): Continuous or repeated ECGs help detect changes in ST segments, arrhythmias, or infarct progression. It’s crucial in monitoring the effectiveness of interventions and early detection of complications.
- Reflux: While reflux may cause chest discomfort, it is not associated with ST elevation or arm radiation. These findings are cardiac in nature and point away from gastrointestinal causes.
- Costochondritis: This musculoskeletal condition causes localized chest pain but does not result in ECG changes or radiating pain. It is not supported by the client's data.
- Atrial fibrillation (A-fib): The client has a normal heart rate and regular rhythm. A-fib would show an irregular rhythm on ECG, not ST elevation, and is not the suspected diagnosis here.
- Insert nasogastric tube (NGT) for nutritional intake: An NGT is not a priority for a client with acute chest pain. The focus should be on stabilizing cardiac function rather than nutritional support.
- Consult nutritionist: Nutritional counseling may be relevant later, but it is not an acute intervention during a suspected myocardial infarction.
- Begin strict bedrest: While activity should be limited, “strict bedrest” is not always necessary and may lead to complications like DVT. The client’s mobility orders depend on cardiac stability.
- Intake and output: While important in general care, it is not as immediately critical in early MI management as pain and ECG monitoring.
- Nutritional intake: Nutritional monitoring is not an immediate priority during acute chest pain evaluation and cardiac stabilization.
- Peripheral edema: Edema may indicate chronic heart failure, but it is not a key indicator for acute myocardial infarction or urgent follow-up in this scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. A description of the chest pain when client is at rest: Determining whether the pain occurs at rest helps differentiate stable from unstable angina. Stable angina typically resolves with rest and is exertion-related, while pain at rest may suggest unstable angina.
B. A demonstration of the activity that precipitates pain: While understanding what provokes the pain is helpful, a physical demonstration is unnecessary and potentially dangerous, especially if it might trigger another anginal episode.
C. A complete seven (7) day diet history of client's oral intake: Dietary intake is not immediately relevant for evaluating recent angina symptoms. Priority should be placed on identifying acute features that may signal unstable angina or myocardial infarction.
D. The client’s blood pressures sitting and standing: Assessing for orthostatic hypotension is useful in evaluating dizziness or syncope but does not directly address the nature or severity of chest pain. It is not the priority assessment for symptoms of angina pectoris following exertion.
Correct Answer is A
Explanation
A. Continue to monitor the client's condition: The ABG values are all within normal limits: pH 7.38, PaCO₂ 40 mm Hg, HCO₃⁻ 24 mEq/L, and PaO₂ 90 mm Hg. This indicates adequate acid-base balance and oxygenation. No immediate intervention is needed, so continued monitoring is the most appropriate nursing action.
B. Encourage the client to cough and deep breathe: Coughing and deep breathing are useful for clearing secretions or improving oxygenation in clients with hypoxia or atelectasis. However, the client’s PaO₂ is within the normal range, so this intervention is unnecessary.
C. Administer oxygen per face mask per PRN protocol: Supplemental oxygen is used when PaO₂ levels are below normal or when signs of respiratory distress are present. Since the client’s PaO₂ is 90 mm Hg, which is normal, there is no need to initiate oxygen therapy.
D. Instruct the client to breathe into a paper bag: Breathing into a paper bag is used to treat hyperventilation leading to respiratory alkalosis. The client’s ABG results do not show alkalosis; therefore, this intervention would be inappropriate and potentially harmful.
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