The nurse is caring for a client diagnosed with a myocardial infarction (MI) who is reporting severe chest pain.Which interventions should the nurse implement? (Select all that apply.)

Place the client in the supine position.

Administer morphine intramuscularly.

Administer nitroglycerin subcutaneously.

Administer aspirin 325 orally.

Apply oxygen via nasal cannula.

Answer and Explanation

Correct Answer : D,E

Choice D rationale

Administering aspirin 325 orally is important for clients with a myocardial infarction (MI). Aspirin helps to inhibit platelet aggregation, reducing the risk of further clot formation and improving blood flow to the heart. This can significantly decrease mortality and complications associated with MI.

Choice E rationale

Applying oxygen via nasal cannula helps to increase oxygen delivery to the heart and other vital organs during an MI. Ensuring adequate oxygenation can help reduce the extent of myocardial injury and support overall cardiac function during a critical period.

Choice A rationale

Placing the client in a supine position is not appropriate during an MI, as it can increase discomfort and the workload on the heart. Instead, the client should be positioned in a semi-Fowler’s or comfortable position to improve breathing and comfort.

Choice B rationale

Administering morphine intramuscularly is not recommended during an MI. Morphine can be used for pain relief but should be given intravenously to ensure rapid onset and better control over dosing. Intramuscular administration is less effective and can delay pain relief.

Choice C rationale

Administering nitroglycerin subcutaneously is not appropriate. Nitroglycerin is typically given sublingually or intravenously during an MI to provide rapid vasodilation and pain relief. Subcutaneous administration is not effective in this context. .

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Correct Answer is D

Explanation

Choice D rationale

Ensuring a clear airway is the priority intervention in cases of diabetic ketoacidosis with hypoxia. Hypoxia refers to a deficiency in the amount of oxygen reaching tissues. Without a clear airway, oxygen cannot be effectively delivered to the lungs, and subsequently to the bloodstream and tissues. Addressing the client's airway ensures that oxygenation can be improved promptly, which is critical in preventing further complications and maintaining vital functions.

Choice A rationale

While it is important to monitor blood glucose levels in diabetic ketoacidosis, it is not the immediate priority when the client is also experiencing hypoxia. Blood glucose testing does not directly address the oxygen deficiency, which needs urgent attention to prevent severe outcomes.

Choice B rationale

Administering a bronchodilator can help improve breathing in some cases; however, it is not the first step in managing hypoxia and diabetic ketoacidosis. The primary focus should be on ensuring a patent airway to facilitate adequate oxygen delivery.

Choice C rationale

Monitoring vital signs is essential in managing any acute condition; however, in this scenario, ensuring a clear airway to address hypoxia is the most critical intervention. Monitoring alone does not resolve the immediate issue of oxygen deprivation.

A. Irrigate the catheter. B. Adjust the rate of the bladder irrigant. C. Notify the provider. D. Check the tubing for kinks.

Correct Answer is D

Explanation

Choice A rationale

Irrigating the catheter without checking for kinks first may not address the underlying issue and can potentially cause harm.

Choice B rationale

Adjusting the rate of the bladder irrigant may not resolve the issue if the catheter tubing is kinked.

Choice C rationale

Notifying the provider without first checking for kinks may delay the resolution of the problem.

Choice D rationale

Checking the tubing for kinks is the first action to ensure there is no obstruction preventing the flow of urine. .

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The nurse is caring for a client diagnosed with a myocardial infarction (MI) who is reporting severe chest pain.Which interventions should the nurse implement? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has diabetic ketoacidosis and hypoxia.Which of the following interventions is most critical to perform immediately?

Correct Answer is D

Explanation

A nurse is caring for a client who is 5 hours postoperative following a transurethral resection of the prostate (TURP). The nurse notes that the client's indwelling urinary catheter has not drained in the past hour.Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

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