The nurse administers IV nitroglycerin to a client diagnosed with an acute myocardial infarction. In evaluating the effectiveness of this intervention, the nurse should monitor for:

decrease in heart rate.

relief of chest pain.

decrease in cardiac dysrhythmias.

decrease in blood pressure.

Answer and Explanation

The Correct Answer is B

A. Decrease in heart rate: While nitroglycerin can sometimes cause reflex tachycardia (an increase in heart rate) as a compensatory mechanism in response to a decrease in blood pressure, its primary effect is on reducing myocardial oxygen demand through vasodilation. Although heart rate may decrease in some situations due to improved perfusion or as a secondary response to pain relief, a decrease in heart rate is not the most reliable or immediate indicator of effectiveness in this context. The relief of chest pain is a more direct measure of the drug's impact.

B. Relief of chest pain: Nitroglycerin works by dilating blood vessels, which reduces myocardial oxygen demand and improves blood flow to the heart, particularly in cases of acute myocardial infarction (MI). The primary therapeutic goal is to relieve chest pain (angina) and reduce the workload of the heart. Monitoring for relief of chest pain is the most direct and important indicator of the medication's effectiveness. If the chest pain decreases or resolves, it suggests that the medication is helping to alleviate the ischemia caused by the MI.

C. Decrease in cardiac dysrhythmias: Nitroglycerin is not primarily used to treat dysrhythmias, although improved perfusion and reduced myocardial oxygen demand may indirectly reduce the occurrence of dysrhythmias in some cases. However, a decrease in dysrhythmias is not a primary goal of nitroglycerin therapy, and the nurse should not primarily monitor for this outcome. Any dysrhythmias should be managed with other specific interventions if needed.

D. Decrease in blood pressure: Nitroglycerin's vasodilatory effect does lead to a reduction in blood pressure, particularly in patients with high blood pressure or in the context of a myocardial infarction. However, excessive hypotension can be dangerous and may lead to inadequate perfusion of vital organs. The nurse must monitor blood pressure closely to avoid hypotension, but a decrease in blood pressure is not the main goal of therapy. The primary objective is to relieve the chest pain associated with the MI. If blood pressure drops too low, it may indicate a need to adjust the dose or discontinue the nitroglycerin.

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Correct Answer is ["A","C","D","E"]

Explanation

A. "How long have you had the pain?"
Asking about the duration of the pain is crucial in assessing a myocardial infarction (MI). The length of time the pain has been occurring can help the nurse determine if the pain is acute or has been ongoing. For instance, chest pain lasting more than 20 minutes or worsening in intensity could indicate an MI. Knowing the timing of the pain also helps establish whether it may be related to acute coronary syndrome (ACS), which requires immediate intervention.

B. "Do you have a history of coronary artery disease?"
While it’s important to understand the patient’s medical history, this question is more secondary during the initial assessment of a client with chest pain. This information is valuable for understanding the risk of cardiovascular events, but it is not the immediate focus when assessing the current pain. The nurse should prioritize questions that address the current symptoms and the characteristics of the pain first.

C. "How would you describe your pain?"
This question is essential to help differentiate the chest pain associated with a myocardial infarction from other causes, such as musculoskeletal pain or gastrointestinal issues. MI pain is typically described as a crushing, pressure-like, or squeezing sensation. Identifying the quality of the pain helps establish whether it’s consistent with a cardiac event. Understanding the description of the pain also provides information about the intensity and potential for myocardial damage.

D. "What were you doing when the pain began?"
This is an important question because activity-related chest pain can help determine the potential cause of the pain. Pain associated with physical exertion or emotional stress may point to an MI or angina. On the other hand, pain unrelated to activity might suggest other causes such as gastrointestinal issues or musculoskeletal pain. Inquiring about the onset of the pain can also provide insight into whether it is associated with physical strain or acute coronary syndrome.

E. "Can you rate your pain on a 0-10 scale?"
Pain assessment using a numeric pain scale (0-10) helps the nurse gauge the severity of the pain and track changes over time. It’s important for determining whether the pain is severe enough to be consistent with an acute myocardial infarction or if it might resolve on its own. This information is vital in deciding the urgency of interventions and treatment decisions.

A. Hand washing before and after client contact B. Placement of an indwelling urinary catheter using sterile technique C. Initiate neutropenic precautions D. Clean technique with central IV line care

Correct Answer is A

Explanation

A. Hand washing before and after client contact: The most important infection control guideline when caring for a client with acute respiratory distress syndrome (ARDS) who is on a ventilator is hand hygiene. This is because ventilated patients are at high risk for ventilator-associated pneumonia (VAP) and other infections. Hand washing is the most effective method of preventing the spread of pathogens that could lead to nosocomial infections. The nurse should perform proper hand hygiene both before and after any patient interaction, as this is critical in preventing the transmission of bacteria or viruses, especially in patients with compromised respiratory systems.

Explanation of each option:

B. Placement of an indwelling urinary catheter using sterile technique:
While using sterile technique when placing an indwelling urinary catheter is essential to prevent urinary tract infections (UTIs), it is not the top priority for infection control in this situation. The primary concern for infection in ARDS patients who are on mechanical ventilation is preventing respiratory infections, particularly ventilator-associated pneumonia (VAP). Although catheter-associated infections should be prevented, the most immediate concern is preventing respiratory-related infections.

C. Initiate neutropenic precautions:
Neutropenic precautions are important for patients who have immunocompromised conditions (such as those undergoing chemotherapy or with bone marrow suppression) to protect them from infections. However, ARDS does not necessarily compromise the immune system in the same way. The priority infection control measure for a patient on a ventilator with ARDS is preventing respiratory infections. Therefore, neutropenic precautions would not be the most relevant or highest priority in this case.

D. Clean technique with central IV line care:
Maintaining clean technique with central intravenous (IV) line care is important to prevent infections, such as central line-associated bloodstream infections (CLABSI). However, the most critical infection control measure for a patient on a ventilator with ARDS is still to focus on preventing respiratory infections, particularly ventilator-associated pneumonia (VAP). While IV line care is important, it is secondary to preventing respiratory tract infections in this scenario.

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The nurse administers IV nitroglycerin to a client diagnosed with an acute myocardial infarction. In evaluating the effectiveness of this intervention, the nurse should monitor for:

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Naxlex Comprehensive Predictor Exams

A client comes to the emergency Department with chest pain and the nurse suspects a myocardial infarction. Which questions) should the nurse ask the client about the pain in the initial assessment? (SELECT ALL THAT APPLY)

Correct Answer is ["A","C","D","E"]

Explanation

The nurse is admitting a client who is on a ventilator. The client has a medical diagnosis of acute respiratory distress syndrome (ARDS). Which infection control guideline is of greatest importance?

Correct Answer is A

Explanation

When caring for a client with a chest tube, the nurse would avoid the practice

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