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

Weighing the client at the same time every day

Assuring hourly urine output of at least 25 mL per hour

Maintaining strict bedrest for the first 24 hours

Providing pain control and reducing oxygen demand

Answer and Explanation

The Correct Answer is D

A. Weighing the client at the same time every day:
While daily weights are important for monitoring fluid status (especially in patients at risk for heart failure or fluid retention), it is not the highest priority in the immediate post-MI period. Weighing the client daily can be useful to track fluid accumulation, but addressing the client’s pain management and oxygenation needs takes precedence in the acute phase of an MI.

B. Assuring hourly urine output of at least 25 mL per hour:
Maintaining adequate urine output (typically around 30 mL per hour) is important to assess renal perfusion and fluid balance, especially if the patient is at risk for renal insufficiency or cardiogenic shock. However, this is not the highest priority immediately following an MI. The first priority is managing the oxygen supply to the heart, and addressing pain and reducing myocardial oxygen demand is more crucial in the acute phase to prevent further damage.

C. Maintaining strict bedrest for the first 24 hours:
Strict bedrest may have been a common practice in the past for patients following an MI, but current guidelines emphasize early mobilization and gradual activity as tolerated to prevent complications like deep vein thrombosis (DVT), pulmonary embolism (PE), and muscle deconditioning. While some degree of rest may be necessary immediately after an MI, the priority is to control pain and reduce oxygen demand, not strictly maintain bedrest. Prolonged immobility is not recommended in the modern management of MI unless there are specific contraindications.

D. Providing pain control and reducing oxygen demand is the most critical intervention in the acute phase of an anterior wall MI. Effective pain relief helps to reduce sympathetic stimulation, which decreases heart rate, blood pressure, and myocardial oxygen demand, preventing further myocardial injury and improving outcomes. This is essential for stabilizing the client early in their post-MI course.

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Correct Answer is D

Explanation

A. In the prone position:
The prone position has been shown to be beneficial in certain respiratory conditions, particularly in acute respiratory distress syndrome (ARDS), where it can help improve oxygenation by redistributing blood flow in the lungs. However, prone positioning is typically not the first choice for pneumonia, especially when it is localized to specific lobes of the lung. It is more commonly used in cases of diffuse bilateral lung injury or severe hypoxemia. Therefore, while prone positioning can improve oxygenation in ARDS, it is not specifically targeted for secretion removal in localized pneumonia.

B. In high-Fowler's position:
The high-Fowler's position (sitting up at a 60-90 degree angle) can help with dyspnea and promote lung expansion in conditions like heart failure or dyspneic states. However, for pneumonia, it is not as effective as lateral positioning for facilitating secretion drainage from specific lung lobes. The high-Fowler's position may be useful for promoting overall comfort and reducing dyspnea, but it is not the best position for improving secretion removal from the right middle and lower lobes.

C. On the left side:
Positioning the patient on the left side is not ideal for right middle and lower lobe pneumonia, as it would not optimize drainage from the affected lobes. The right middle and lower lobes are better drained when the patient is positioned on the right side, as gravity can help move the secretions from the affected lobes toward the larger airways for easier clearance.

D. On the right side: In the case of right middle and lower lobe pneumonia, positioning the client on the right side can help optimize ventilation and promote better secretion removal from the affected areas of the lung. This position allows gravity to assist in draining secretions from the right middle and lower lobes toward the larger airways, where they can be more easily cleared by coughing or suctioning. This positioning can improve oxygenation and facilitate secretion management, which is crucial for improving respiratory function in pneumonia.

A. respiratory rate of 10 breaths per minute. B. respiratory rate of 32 breaths per minute. C. blood pressure 86/42 mmHg. D. heart rate of 45 beats per minute.

Correct Answer is B

Explanation

Explanation of each option:

A. Respiratory rate of 10 breaths per minute:
A respiratory rate of 10 breaths per minute would be too slow in a patient with ARDS and hypoxemia. In response to hypoxemia, the body typically increases the respiratory rate to improve oxygenation. A respiratory rate of 10 breaths per minute would not be expected in this situation.

B. Respiratory rate of 32 breaths per minute: The arterial blood gas (ABG) results indicate respiratory alkalosis with hypoxemia, which is a common finding in patients with acute respiratory distress syndrome (ARDS). pH 7.59: This is alkalotic, meaning the body is experiencing respiratory alkalosis.

PaCO2 29 mmHg: The PaCO2 is low, indicating hyperventilation, which is a compensatory response to the alkalosis in an attempt to reduce carbon dioxide levels.

PaO2 55 mmHg: This is severely low, indicating hypoxemia (low oxygen levels in the blood), a hallmark of ARDS. HCO3 22 mEq/L: The bicarbonate is normal, suggesting that the metabolic component has not yet compensated for the respiratory alkalosis, or that it is in the early stages of compensation. Given these ABG results, the body is attempting to compensate for hypoxemia by increasing respiratory rate (tachypnea), which leads to hyperventilation and further reduction in PaCO2. Therefore, an expected assessment finding in this scenario would be a high respiratory rate (such as 32 breaths per minute), which is a compensatory response to hypoxemia.

C. Blood pressure 86/42 mmHg:
While hypotension can occur in severe cases of ARDS due to impaired oxygenation and circulation, it is not directly reflected by the ABG results provided. Hypoxemia and alkalosis would more likely lead to tachypnea and compensatory mechanisms like tachycardia, rather than significant hypotension unless there is another contributing factor, such as shock or sepsis. Therefore, hypotension is not the most expected finding based on these ABGs.

D. Heart rate of 45 beats per minute:
A heart rate of 45 beats per minute is bradycardic, which would be unusual in a patient with hypoxemia and respiratory alkalosis. Tachycardia is a more common compensatory response to hypoxia, as the heart works harder to improve oxygen delivery to tissues. A heart rate of 45 beats per minute would be more suggestive of a different underlying condition, such as vagal stimulation or cardiac conduction issues, but it is not the expected response in this case.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client diagnosed with acute respiratory failure as a result of right middle and lower lobe pneumonia. To optimize ventilation and secretion removal the nurse should position the client:

Correct Answer is D

Explanation

Correct Answer is B

Explanation

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