Which nursing intervention is highest priority for the client who has suffered an acute anterior wall mycordial infarction?

Maintaining strict bedrest for first 24 hours

Measuring urine output hourly and performing daily weighs

Keeping the environment quiet to decrease cardiac workload

Reducing oxygen demand and providing pain control

Answer and Explanation

The Correct Answer is D

A) Maintaining strict bedrest for first 24 hours:
While bedrest is often recommended in the early stages following a myocardial infarction (MI), the priority nursing intervention is to reduce oxygen demand on the heart, which can be achieved through pain management and controlling the workload on the heart, rather than solely relying on bedrest. Bedrest alone may not address the underlying physiological needs of the heart, such as reducing ischemia or controlling pain.

B) Measuring urine output hourly and performing daily weights:
Monitoring urine output and performing daily weights are important in managing fluid balance, especially for those with heart failure or volume overload. However, in the acute phase of an anterior wall myocardial infarction, the priority intervention is addressing the oxygen demand on the heart and providing pain relief, which is more immediate in stabilizing the client and reducing myocardial injury.

C) Keeping the environment quiet to decrease cardiac workload:
While creating a calm and quiet environment helps in reducing stress and decreasing cardiac workload, it is still secondary to actively managing the oxygen demand of the heart. Decreasing the workload of the heart is essential, but this is done more effectively through interventions such as pain management, oxygen therapy, and medications that reduce myocardial oxygen demand (e.g., nitroglycerin, beta-blockers).

D) Reducing oxygen demand and providing pain control:
This is the highest priority intervention for a client who has suffered an acute anterior wall myocardial infarction (MI). Pain from an MI increases the heart's oxygen demand and can exacerbate ischemia. Pain relief, often with morphine, not only reduces pain but also helps in vasodilation, reducing the heart's workload. Additionally, oxygen therapy should be given to ensure adequate oxygenation, and medications like beta-blockers, nitroglycerin, and ACE inhibitors are used to reduce the workload of the heart.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

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

Explanation

A) O- (O negative):
A person with blood type A- can safely receive blood from a universal donor blood type, which is O-. This is because O- has no A, B, or Rh antigens on the surface of its red blood cells, making it compatible with any ABO blood group. The Rh negative status is also compatible, as the recipient is also Rh-negative.

B) AB- (AB negative):
A person with blood type A- cannot receive blood from someone with AB-. This is because the AB- blood type contains both A and B antigens on the surface of red blood cells, which could cause an immune reaction in a person with A- blood, whose immune system will react against the B antigen. Therefore, AB- is not compatible with A- blood.

C) A+ (A positive):
A person with A- blood cannot receive blood from an A+ donor, because the A+ blood contains the Rh positive antigen. If a person with A- blood receives Rh-positive blood, they will form antibodies against the Rh factor, leading to a hemolytic transfusion reaction. Therefore, A+ is not compatible with A- blood.

D) A- (A negative):
A person with A- blood can receive blood from another A- donor, because both share the A antigen and are Rh-negative. This is a perfect match and poses no risk of a transfusion reaction.

E) O+ (O positive):
A person with A- blood cannot receive blood from an O+ donor, because the O+ blood contains the Rh-positive antigen. This could cause an immune reaction in a person with A- blood, leading to the production of anti-Rh antibodies. Therefore, O+ is not compatible with A- blood.

A. Prepare for a STAT computed topography scan (CT) B. Obtain a 12 lead electrocardiogram C. Start an intravenous infusion of D5W at 100 mL/hr D. Administer a nonnarcotic analgesics

Correct Answer is A

Explanation

A) Prepare for a STAT computed tomography (CT) scan:
A severe headache in a client with a suspected stroke could be indicative of increased intracranial pressure (ICP), a hemorrhagic stroke, or another serious complication like cerebral edema. The priority intervention is to perform a CT scan to determine whether the stroke is ischemic (caused by a blockage) or hemorrhagic (caused by bleeding). This is crucial because the treatment approach for these two types of strokes differs significantly. For example, hemorrhagic strokes require immediate management to control bleeding and reduce ICP, whereas ischemic strokes may be treated with thrombolytics or other interventions. Therefore, preparing for a CT scan is the most urgent action to accurately diagnose the type of stroke and guide treatment decisions.

B) Obtain a 12-lead electrocardiogram (ECG):
While an ECG may be useful in assessing the cardiac rhythm and identifying potential arrhythmias (which can contribute to stroke risk), it is not the priority intervention in a patient with a suspected stroke and severe headache. The primary concern is to identify the type of stroke (ischemic or hemorrhagic), and a CT scan is the most direct way to do this. A 12-lead ECG can be obtained later if cardiac issues are suspected after stroke diagnosis.

C) Start an intravenous infusion of D5W at 100 mL/hr:
Starting an IV infusion of D5W (5% dextrose in water) is not an appropriate priority for a patient with a severe headache and suspected stroke. In fact, administering dextrose solutions may worsen the patient's condition in the case of a hemorrhagic stroke, as it could exacerbate cerebral edema or increase intracranial pressure. Fluid management in stroke patients should be approached cautiously, and IV fluids should be tailored to the patient's specific needs. The focus should be on imaging to determine the type of stroke before initiating interventions like IV fluids.

D) Administer a nonnarcotic analgesic:
While pain relief is important, administering a nonnarcotic analgesic (such as acetaminophen or ibuprofen) is not the priority in this situation. The patient's severe headache could be a sign of a serious complication like increased ICP or hemorrhagic stroke, which requires immediate diagnostic workup, not just pain management. Administering pain medication without understanding the underlying cause of the headache could mask symptoms and delay critical treatment.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Which nursing intervention is highest priority for the client who has suffered an acute anterior wall mycordial infarction?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing to administer a unit of packed red blood cells (PRBC's) to a patient whose blood type is A- (negative). The nurse knows that this patient can receive transfusions from which blood types? (SELECT ALL THAT APPLY).

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

Explanation

A client diagnosed with a stroke complains of a severe headache. Which intervention would be the nursing priority?

Correct Answer is A

Explanation

The nurse is providing education to the client diagnosed with multiple sclerosis (MS) about baclofen. What statement made by the client would indicate to the nurse that the client understood the education? The client states ‘’I will

The nurse is caring for a client diagnosed with acute coronary syndrome who has just returned to the nursing unit following an intracoronary stent insertion. Which action is the priority at this time?

The client Is in the intensive care unit on a ventilator. Which intervention(s) should the nurse implement? (SELECT ALL THAT APPLY)

Which instruction is most important for the nurse to provide a client who is receiving radiation therapy for lung cancer when teaching about skin care?

The nurse is caring for a client with infectious endocarditis. Which information obtained from the health history could have contributed to the development of the disease progress?

A young adult is brought to the Emergency Department (ED) after a motor vehicle accident (MVA). The patient has severe right chest pain where there was impact with the steering wheel. Which is the priority patient goal?

The nurse is caring for a patient with multiple traumatic injuries following an occupational accident where the patient fell from a 30ft high ladder. Upon assessment, the-nurse hears bowel sounds in the chest. What should the nurse do next?

The client diagnosed with Parkinson's Disease (PD) is being admitted with a fever and patchy infiltrates in the lung fields on the chest x-ray. Which clinical manifestations of PD would explain this assessment data?