The nurse is planning care for the client. Which of the following provider prescriptions should the nurse anticipate? Select All That Apply
Administer morphine 4 mg IV bolus
Prepare client for an exercise tolerance test.
Administer an intermittent IV fluid bolus.
Administer nitroglycerin sublingual.
Place the client in the supine position.
Apply oxygen at 2 L/min via nasal cannula.
Prepare client for percutaneous coronary intervention.
Correct Answer : A,D,F,G
Rationale:
A. Administer morphine 4 mg IV bolus: Morphine is appropriate for severe chest pain unrelieved by nitrates. It decreases preload, pain, and anxiety, reducing myocardial oxygen demand. This intervention helps improve comfort and may lower sympathetic nervous system activation during an acute MI.
B. Prepare client for an exercise tolerance test: This is contraindicated during active chest pain and elevated troponin levels. Stress testing would increase cardiac workload and worsen ischemia. It is only done when a patient is stable and MI has been ruled out.
C. Administer an intermittent IV fluid bolus: Fluid boluses are not indicated unless hypotension or hypovolemia is present. Extra fluid can increase cardiac workload and worsen outcomes in MI. In a normotensive patient with chest pain, it offers no benefit and may increase risk of pulmonary congestion.
D. Administer nitroglycerin sublingual: Nitroglycerin is a first-line medication for ischemic chest pain. It improves blood flow by dilating coronary arteries and reducing cardiac preload. It can rapidly relieve angina and should be administered as soon as possible in acute chest pain.
E. Place the client in the supine position: Supine positioning may worsen breathing difficulty and is not ideal during acute chest pain. A semi-Fowler's position is better to support oxygenation. Keeping the head elevated helps reduce venous return and cardiac workload.
F. Apply oxygen at 2 L/min via nasal cannula: Oxygen is appropriate with labored respirations and signs of hypoxia. It improves oxygen delivery to the myocardium during ischemic events. Supplemental oxygen can help stabilize oxygen saturation while definitive interventions are underway.
G. Prepare client for percutaneous coronary intervention: PCI is a key treatment for myocardial infarction and should be anticipated given the client’s chest pain, elevated troponin, and high risk profile. It restores perfusion to the affected coronary artery and reduces infarct size and mortality when performed promptly.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.5"]
Explanation
Calculation:
Calculate the total desired dose in mg:
Desired dose (mg) = Weight (kg) x Ordered dose (mg/kg)
Desired dose (mg) = 69.9 kg x 0.75 mg/kg
Desired dose (mg) = 52.425 mg
Determine the volume to administer using the available concentration:
Volume to administer (mL) = Desired dose (mg) / Available concentration (mg/mL)
First, find the concentration in mg/mL:
60 mg / 0.6 mL = 100 mg/mL
Now, calculate the volume:
Volume to administer (mL) = 52.425 mg / 100 mg/mL
Volume to administer (mL) = 0.52425 mL
Round the answer to the nearest tenth:
0.52425 mL rounded to the nearest tenth is 0.5 mL.
Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"E"}
Explanation
Rationale:
- Elevated blood glucose: A random glucose level of 220 mg/dL is mildly elevated and can be expected during acute illness or stress, especially in clients with diabetes. It should be monitored but does not require immediate intervention in this cardiac context.
- Elevated heart rate: A heart rate of 116/min reflects tachycardia, which may result from pain, anxiety, or reduced cardiac output. While it is an important finding, it is secondary to more urgent issues like chest pain or myocardial injury.
- Epigastric discomfort: Epigastric discomfort alone is not an emergency finding and can occur in non-cardiac conditions such as GERD or peptic ulcer disease. While it may signal atypical angina, it lacks the specificity or urgency of active chest pain.
- Chest pain: Chest pain is a classic symptom of myocardial ischemia and warrants immediate intervention. The nurse should apply oxygen, initiate cardiac monitoring, assess pain characteristics, establish IV access, and prepare to administer nitroglycerin or aspirin per protocol.
- Elevated troponin: A troponin level of 10.15 ng/mL confirms myocardial injury and supports the diagnosis of myocardial infarction. The nurse should report this result immediately, anticipate further cardiac workup, continue ECG and vital monitoring, and prepare the client for possible transfer to a higher level of care.
- Elevated blood pressure: A BP of 158/92 mm Hg is elevated but not critical in this context. It is likely a response to pain or anxiety and can be managed after more urgent issues, such as ischemia or infarction, have been addressed.
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