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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

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

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is A

Explanation

A. Suction the client as needed: Suctioning is an essential nursing intervention for clients on mechanical ventilation to maintain effective ventilation. Ventilated clients are at risk for accumulating secretions in the airway, which can obstruct the endotracheal tube or tracheostomy, impairing ventilation and oxygenation. Regular or as-needed suctioning helps to clear secretions, ensuring that the airway remains patent and effective ventilation is maintained. This intervention directly supports the goal of maintaining optimal respiratory function and preventing complications such as atelectasis, pneumonia, or hypoxia.

B. Administer pantoprazole sodium IV: Pantoprazole is a proton pump inhibitor used to decrease stomach acid, typically to prevent stress ulcers in critically ill patients. While this is an important aspect of care for preventing gastrointestinal complications in ventilated patients, it does not directly support ventilation. Therefore, administering pantoprazole is not as directly related to ensuring effective ventilation as suctioning or other respiratory interventions.

C. Apply sequential compression device (SCD): While applying an SCD is important for preventing deep vein thrombosis (DVT) and promoting circulation in immobile patients, it does not directly address the client's ventilation or respiratory function. This intervention is more relevant for preventing venous thromboembolism, not for managing ventilation or airway clearance.

D. Perform oral care with chlorhexidine: Oral care with chlorhexidine is an important practice to reduce the risk of ventilator-associated pneumonia (VAP) and promote overall oral hygiene. It helps decrease the colonization of bacteria in the mouth and reduces the risk of infection. However, while oral care is an essential component of care for a ventilated patient, suctioning directly addresses the goal of effective ventilation by maintaining airway patency, making it the most immediate and relevant intervention for supporting ventilation.

A. Administer antiplatelet and anticoagulant medications to prevent further clot formation. B. Relieve the blockage in the coronary artery and restore blood flow to the heart muscle. C. Provide pain relief and initiate cardiac rehabilitation. D. Stabilize the dient's blood pressure and administer thrombolytic therapy.

Correct Answer is B

Explanation

A) Administer antiplatelet and anticoagulant medications to prevent further clot formation:
While antiplatelet and anticoagulant medications are essential in the management of STEMI to reduce the risk of further clot formation, they are not the primary goal of treatment in the immediate phase. These medications are typically administered before or during the procedure (such as during cardiac catheterization) to prevent new clots, but the primary objective is to restore blood flow to the heart muscle through reperfusion therapy, either by angioplasty or thrombolytics.

B) Relieve the blockage in the coronary artery and restore blood flow to the heart muscle:
This is the primary goal of treatment in STEMI. The most urgent intervention for a client with an ST elevation myocardial infarction (STEMI) is to relieve the blockage in the coronary artery and restore blood flow to the ischemic heart muscle. This is typically achieved through percutaneous coronary intervention (PCI) via cardiac catheterization, which involves either angioplasty (ballooning the artery) or stent placement. Restoring blood flow as quickly as possible reduces the extent of myocardial damage, improves the prognosis, and prevents complications like heart failure.

C) Provide pain relief and initiate cardiac rehabilitation:
Pain relief is important in the initial management of STEMI, typically with nitroglycerin and opioids for chest pain. However, the immediate goal in the ED is to address the underlying cause of the chest pain, which is the blockage of blood flow. Cardiac rehabilitation, while essential for long-term recovery, is not the immediate goal of treatment during the acute phase of a STEMI. The primary focus should be on restoring circulation to the affected myocardium.

D) Stabilize the client's blood pressure and administer thrombolytic therapy:
Stabilizing the client’s blood pressure is important, especially if the client is hypotensive, but it is not the main treatment goal. Thrombolytic therapy (clot-busting medications) is an option if PCI is not available or if it needs to be done within a certain time frame; however, the current best practice in STEMI is to perform PCI as soon as possible. Thrombolytics are typically used when PCI is not immediately available, but the ideal treatment is to restore blood flow through catheterization in a timely manner, as it is more effective than thrombolytic therapy at re-opening the blocked artery.

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

Arterial Blood Gases
pH	7.35-7.45
PaCO2	35-45mmHg
PaO2	80-100mmHg
HCO3-	22-26 mEq/L
O2 Saturation	>95%
Chemistry
BUN	8-21mg/dl
Creatinine	0.5-1.2mg/dl
Na	135-145 mEq/L
K	3.5-5.3 mEq/L
Cl	97-107 mEq/L
CO2	22-26 mEq/L
Ca	8.2-10.2 mg/dl
Glucose	65-99 mg/dl
Mg	1.7-2.2 mg/dl
PO4	2.5-4.5 mg/dl

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

To achieve the outcome of effective ventilation, which nursing intervention should be included in the plan of care for a client on a ventilator?

Correct Answer is A

Explanation

A client is admitted to the Emergency Department (ED) with a suspected ST elevation myocardial infarction (STEMI) involving the inferior wall. The nurse anticipates that this client will be immediately scheduled for the cardiac catheterization laboratory. The goal of treatment is to:

Correct Answer is B

Explanation

The nurse is caring for a client receiving mechanical ventilation. The nurse hears the low-pressure alarm sound. After checking the client and ventilator, the nurse cannot determine the source of the alarm. What should the nurse do next?

A client comes to the emergency Department with chest pain and the nurse suspects a myocardial infarction. Which questions) should the nurse ask the client about the pain in the initial assessment? (SELECT ALL THAT APPLY)

The nurse is caring for a client diagnosed with amyotrophic lateral sclerosis (ALS). The client was given a medical prescription for tizanidine. What information would the nurse provide regarding this medication? Tizanidine is

The nurse prepares discharge instructions for the client diagnosed with a myocardial infarction. Which client statement indicates a need for further education? "I will take:

Which of the following assessment findings in a client who is receiving atenolol for angina would be a cause for the nurse to hold the medication and contact the provider?