When entering the room to administer scheduled daily medications, the nurse observes the client leaning forward and using pursed-lip breathing. Which action is most important for the nurse to take?

Auscultate the lungs for evidence of wheezing.

Quickly administer scheduled medications.

Ask the client if an anxiolytic is needed.

Evaluate the client's oxygen saturation.

Answer and Explanation

The Correct Answer is D

A. Auscultate the lungs for evidence of wheezing: Lung auscultation is helpful in assessing respiratory status, but evaluating oxygen saturation is more urgent in this situation. It provides an immediate, objective measure of gas.

B. Quickly administer scheduled medications: Administering medications without assessing the client’s respiratory status may be unsafe. The client’s posture and breathing pattern suggest respiratory distress, which should be evaluated before giving medications.

C. Ask the client if an anxiolytic is needed: Anxiety may worsen breathing, but the client’s body language likely indicates a physiological rather than psychological problem. Assessing oxygenation is more important than addressing anxiety in this context.

D. Evaluate the client’s oxygen saturation: Pursed-lip breathing and forward-leaning posture are compensatory mechanisms seen in respiratory distress, often in clients with COPD. Assessing oxygen saturation immediately helps determine the severity of hypoxia and guides appropriate interventions.

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Correct Answer is B

Explanation

A. Assist with ambulation in the hallway: While progressive ambulation is part of cardiac rehabilitation, early ambulation too soon after a myocardial infarction may increase myocardial oxygen demand and cardiac workload.

B. Provide a bedside commode for toileting: Using a bedside commode reduces the effort and energy expenditure required to walk to the bathroom, thus lowering cardiac workload. This helps prevent unnecessary increases in heart rate and oxygen demand.

C. Encourage active range of motion exercise: Active range of motion is beneficial for preventing complications like thromboembolism, but if done too aggressively or frequently early post-MI, it can stress the heart.

D. Teach to sleep in a side-lying position: Sleeping position may affect comfort and breathing but does not significantly influence cardiac workload. Semi-Fowler’s position may be more beneficial in reducing preload in cardiac patients than simply lying on the side.

Correct Answer is []

Explanation

Myocardial infarction (MI): The client reports chest pain rated 8/10, radiating to the left arm, and has ST segment elevation on ECG. These findings are classic for ST-elevation myocardial infarction (STEMI), requiring immediate intervention.
Draw laboratory cardiac markers: Troponin and other cardiac enzymes are critical for confirming myocardial injury. They help guide diagnosis, treatment, and monitoring of MI progression or resolution.
Insert two peripheral IV (PIV) access devices: Dual IV access ensures reliable and rapid administration of emergency medications, fluids, or thrombolytics. This is vital for stabilizing the client during acute cardiac events.
Pain level: Ongoing pain assessment is essential for monitoring myocardial ischemia, evaluating treatment response, and guiding further interventions to prevent cardiac tissue damage.
12-lead electrocardiogram (ECG): Continuous or repeated ECGs help detect changes in ST segments, arrhythmias, or infarct progression. It’s crucial in monitoring the effectiveness of interventions and early detection of complications.

Reflux: While reflux may cause chest discomfort, it is not associated with ST elevation or arm radiation. These findings are cardiac in nature and point away from gastrointestinal causes.
Costochondritis: This musculoskeletal condition causes localized chest pain but does not result in ECG changes or radiating pain. It is not supported by the client's data.
Atrial fibrillation (A-fib): The client has a normal heart rate and regular rhythm. A-fib would show an irregular rhythm on ECG, not ST elevation, and is not the suspected diagnosis here.
Insert nasogastric tube (NGT) for nutritional intake: An NGT is not a priority for a client with acute chest pain. The focus should be on stabilizing cardiac function rather than nutritional support.
Consult nutritionist: Nutritional counseling may be relevant later, but it is not an acute intervention during a suspected myocardial infarction.
Begin strict bedrest: While activity should be limited, “strict bedrest” is not always necessary and may lead to complications like DVT. The client’s mobility orders depend on cardiac stability.
Intake and output: While important in general care, it is not as immediately critical in early MI management as pain and ECG monitoring.
Nutritional intake: Nutritional monitoring is not an immediate priority during acute chest pain evaluation and cardiac stabilization.
Peripheral edema: Edema may indicate chronic heart failure, but it is not a key indicator for acute myocardial infarction or urgent follow-up in this scenario.

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When entering the room to administer scheduled daily medications, the nurse observes the client leaning forward and using pursed-lip breathing. Which action is most important for the nurse to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client recovering from a recent myocardial infarction. To reduce cardiac workload, which intervention should the nurse include in the client's plan of care?

Correct Answer is B

Explanation

Exhibits The nurse reviews chart data. Complete the diagram by dragging from the choices area which potential condition the client is experiencing, two actions to take, and two parameters the nurse would monitor.

Correct Answer is []

Explanation

When entering the room to administer scheduled daily medications, the nurse observes the client leaning forward and using pursed-lip breathing. Which action is most important for the nurse to take?

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A client with a history of anxiety and asthma had an open cholecystectomy 3 days ago. Shortly after ambulating to the bathroom, the client is restless and troubled by shortness of breath. Which action should the nurse implement first?