In planning care for a patient with acute myocardial infarction (AMI), which of the following should the nurse identify as the highest priority goal of care?
Stable ECG rhythm
Ability to verbalize causes and effects of CHD/CAD
Adequate relief of pain
Compliance with prescribed bedrest
The Correct Answer is C
Choice A reason : While maintaining a stable ECG rhythm is important, it is not the highest priority. The primary concern is to address life-threatening complications.
Choice B reason : Educating the patient about the causes and effects of coronary heart disease (CHD) or coronary artery disease (CAD) is important for long-term management but is not the immediate priority during acute care.
Choice C reason : Adequate relief of pain is the highest priority in the care of a patient with AMI. Pain is an indicator of ongoing ischemia and can increase the workload of the heart, thereby worsening the condition.
Choice D reason (AMI): While bedrest is part of the care plan, it is not the highest priority compared to pain relief, which has direct implications on the patient's immediate physiological status.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Hyperkalemia is a common electrolyte imbalance in prerenal AKI due to decreased kidney function and the inability to excrete potassium.
Choice B reason: Hypernatremia is not typically expected in prerenal AKI unless there is an associated condition causing increased sodium retention.
Choice C reason: Hypercalcemia is not commonly associated with prerenal AKI.
Choice D reason: Hypophosphatemia is less likely in prerenal AKI; hyperphosphatemia is more common due to decreased filtration of phosphate.
Correct Answer is D
Explanation
Choice A reason: An INR of 0.9 is within the normal range (0.8-1.2) and does not support the presence of bruising or bleeding disorders.
Choice B reason: A hematocrit level of 28% is below the normal range (36%-50% for women, 40%-54% for men), indicating anemia, but it does not directly explain bruising or petechiae.
Choice C reason: A WBC count of 4500 is within the normal range (4500-11000), suggesting that there is no active infection or leukocytosis that would explain the bruising.
Choice D reason: A platelet count of 60000 is below the normal range (150000-450000), which can lead to easy bruising and petechiae, supporting the nurse's observation.
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