The nurse is providing care for a client admitted to rule out a myocardial infarction who is experiencing chest pain while walking to the bathroom. Which action should the nurse implement first?

Obtain a STAT electrocardiogram

Have the client sit down immediately

Assess the client's vital signs

Administer sublingual nitroglycerin

Answer and Explanation

The Correct Answer is B

A. Obtaining an ECG is important but not the first action. The priority is to stop activity, as exertion can worsen myocardial oxygen demand.
B. Having the client sit down immediately is correct. Stopping activity reduces cardiac workload and oxygen demand, preventing further ischemia or infarction.
C. Assessing vital signs is important but should follow stopping activity. Chest pain requires immediate action to reduce cardiac strain.
D. Administering sublingual nitroglycerin is appropriate but should be done after ensuring the client is seated. This prevents hypotension and syncope from occurring while standing.

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Correct Answer is C

Explanation

A. Brain Natriuretic Peptide (BNP) is a marker for heart failure, not the primary diagnostic test for myocardial infarction (MI).
B. Total Lactate Dehydrogenase (LDH) was historically used but is not specific for MI and has been replaced by troponin testing.
C. Troponin is correct. Cardiac-specific troponins (Troponin I and Troponin T) are the gold standard for detecting myocardial injury. Elevated levels indicate myocardial damage and are crucial for diagnosing MI.
D. Creatinine is important for assessing kidney function but is not a marker for myocardial infarction.

A. Weight loss B. Dry mouth C. Hyperglycemia D. Decreased wound healing

Correct Answer is A

Explanation

A. Weight loss is not a common side effect of prednisone. Instead, weight gain due to fluid retention and increased appetite is a frequent side effect.
B. Dry mouth can occur with prednisone use, though it is not the most common side effect.
C. Hyperglycemia is a well-known side effect because corticosteroids increase glucose production and reduce insulin sensitivity.
D. Decreased wound healing is a common effect due to prednisone's immunosuppressive and anti-inflammatory properties, which impair tissue repair.

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The nurse is providing care for a client admitted to rule out a myocardial infarction who is experiencing chest pain while walking to the bathroom. Which action should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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Correct Answer is A

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