The ED nurse is assessing a 48-year-old female (sex at birth) client who has a history of diabetes. Which of the following signs and symptoms would cause the nurse to expect that the client may be experiencing a myocardial infarction? Select all that apply.

Nausea

Increased urinary output

Excessive thirst

Heartburn

Palpitations

Answer and Explanation

Correct Answer : A,D,E

A. Nausea: Nausea is a common symptom of myocardial infarction (MI), especially in women. It results from autonomic nervous system activation and decreased cardiac output, which can stimulate the vomiting center in the brain. Recognizing nausea alongside other cardiac symptoms helps differentiate MI from gastrointestinal issues.

B. Increased urinary output: Polyuria is more commonly associated with uncontrolled diabetes or hyperglycemia, not acute myocardial infarction. During an MI, decreased cardiac output can actually reduce renal perfusion, often leading to oliguria rather than increased urine production.

C. Excessive thirst: Polydipsia is primarily a sign of hyperglycemia or dehydration rather than myocardial ischemia. While diabetes may contribute to fluid imbalance, excessive thirst is not a direct indicator of MI and should be assessed in the context of blood glucose levels.

D. Heartburn: Epigastric discomfort or a sensation of heartburn can be an atypical presentation of MI, particularly in women. Cardiac ischemia may present as upper abdominal pressure or indigestion-like pain rather than classic chest pain, making this symptom clinically significant in assessment.

E. Palpitations: Palpitations may occur during an MI due to arrhythmias caused by ischemic myocardium. Rapid, irregular, or skipped beats signal cardiac electrical instability and warrant immediate evaluation in the context of other MI symptoms.

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Correct Answer is ["B","E"]

Explanation

A. Provide oral care every 12 hours: Oral care is an essential component of VAP prevention; however, every 12 hours is insufficient for mechanically ventilated patients. Evidence-based bundles recommend more frequent oral care, often every 2–4 hours, typically with chlorhexidine to reduce oropharyngeal colonization. This frequency does not meet best-practice standards.

B. Monitor ETT cuff pressure: Maintaining appropriate endotracheal tube cuff pressure (usually 20–30 cm H₂O) helps prevent microaspiration of contaminated oral and gastric secretions into the lower airway. Inadequate cuff pressure increases the risk of pathogen entry into the lungs, making regular monitoring a critical VAP prevention strategy.

C. Insert a nasogastric tube: Insertion of a nasogastric tube does not prevent VAP and may increase the risk of aspiration if not managed properly. Gastric distention and reflux can contribute to aspiration of gastric contents, thereby increasing pneumonia risk rather than reducing it.

D. Administer high doses of sedation: High sedation levels suppress cough reflexes, impair early mobilization, and prolong mechanical ventilation duration, all of which increase VAP risk. Current evidence supports daily sedation interruption and light sedation strategies rather than deep sedation.

E. Maintain head of the bed to at least 30 degrees: Elevating the head of the bed between 30–45 degrees reduces the risk of aspiration of gastric and oral secretions. This positioning decreases the likelihood of bacteria entering the lower respiratory tract and is a cornerstone of ventilator bundle protocols.

A. Echocardiogram results with an ejection fraction of 55% B. BNP results of 155 pg/mL (reference range <100 pg/mL) C. EKG results of sinus rhythm with occasional premature ventricular contractions (PVCS) D. ABG result with a PaCO2 of 30 mmHg (reference range 35-45 mmHg)

Correct Answer is B

Explanation

A. Echocardiogram results with an ejection fraction of 55%: An ejection fraction (EF) of 55% is within the normal range, indicating preserved systolic function. While some forms of heart failure, such as HFpEF (heart failure with preserved ejection fraction), can occur, a normal EF alone does not strongly suggest acute heart failure as the cause of shortness of breath.

B. BNP results of 155 pg/mL (reference range <100 pg/mL): Brain natriuretic peptide (BNP) is released in response to ventricular stretch and increased intracardiac pressures. A BNP of 155 pg/mL is elevated, supporting a cardiac etiology of dyspnea, such as acute or chronic heart failure. BNP is a sensitive and specific biomarker for distinguishing heart failure from other causes of shortness of breath.

C. EKG results of sinus rhythm with occasional premature ventricular contractions (PVCs): Sinus rhythm with occasional PVCs does not indicate heart failure. While arrhythmias may coexist with heart failure, this finding alone does not explain the patient’s dyspnea or support a heart failure diagnosis.

D. ABG result with a PaCO2 of 30 mmHg (reference range 35-45 mmHg): A low PaCO2 reflects hyperventilation, which may be a compensatory response to hypoxia or pulmonary pathology. While it provides information on respiratory status, it is nonspecific and does not directly indicate heart failure as the underlying cause of dyspnea.

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The ED nurse is assessing a 48-year-old female (sex at birth) client who has a history of diabetes. Which of the following signs and symptoms would cause the nurse to expect that the client may be experiencing a myocardial infarction? Select all that apply.

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Naxlex Comprehensive Predictor Exams

Correct Answer is ["B","E"]

Explanation

The nurse is analyzing the diagnostic test results of a patient who is in the emergency department for shortness of breath. Which diagnostic test result does the nurse anticipate to suggest the cause of the shortness of breath is from heart failure?

Correct Answer is B

Explanation

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The ED nurse is assessing a 48-year-old female (sex at birth) client who has a history of diabetes. Which of the following signs and symptoms would cause the nurse to expect that the client may be experiencing a myocardial infarction? Select all that apply.