A client has chest pain rated 8/10 as stated by the patient. The 12-lead ECG reveals ST elevation in the inferior leads and the lab results reveal cardiac enzyme levels are elevated. What is the highest priority for nursing management of this client at this time?
Monitor daily weights and urine output.
Administer TPA to prevent further damage as a result of a clot.
Provide client education on medications and diet to prevent recurrence.
Reduce pain and myocardial oxygen demand.
The Correct Answer is D
A. Monitor daily weights and urine output.
Monitoring daily weights and urine output is an important aspect of managing heart failure or other cardiac conditions. However, in the context of a client with chest pain, ST elevation, and elevated cardiac enzymes (indicating a myocardial infarction), the immediate focus is on addressing the acute event and reducing myocardial oxygen demand.
B. Administer TPA to prevent further damage as a result of a clot.
Tissue plasminogen activator (TPA) is a thrombolytic medication that can be administered to dissolve blood clots in the coronary arteries during a myocardial infarction. However, the administration of TPA has a specific timeframe within which it is most effective. It is crucial to know the elapsed time since the onset of symptoms, and there are specific criteria and contraindications for its use.
C. Provide client education on medications and diet to prevent recurrence.
Client education on medications, lifestyle modifications, and dietary changes is an essential component of long-term management for preventing recurrence of cardiovascular events. However, during the acute phase of a myocardial infarction, the immediate priority is to stabilize the client and address the acute event, with education being a secondary consideration.
D. Reduce pain and myocardial oxygen demand.
During the acute phase of a myocardial infarction, reducing pain and myocardial oxygen demand is the highest priority. This is typically achieved through the administration of medications such as nitroglycerin for vasodilation and opioids for pain relief. Other interventions to optimize oxygen supply and demand, such as supplemental oxygen and reperfusion strategies, may also be considered.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Diaphragmatic breathing:
Diaphragmatic breathing, also known as abdominal or deep breathing, is a normal and effective way of breathing. It involves the contraction and relaxation of the diaphragm, allowing for efficient lung expansion. This is a healthy and efficient breathing technique.
B. Controlled breathing:
Controlled breathing refers to a deliberate and regulated breathing pattern. It can include techniques such as paced breathing, where the individual consciously controls the rate and depth of their breaths. Controlled breathing is generally considered a positive and intentional approach to managing respiratory function.
C. Pursed-lip breathing:
Pursed-lip breathing is a breathing technique where the individual breathes in through the nose and exhales through pursed lips. This method is often taught to individuals with certain respiratory conditions, such as chronic obstructive pulmonary disease (COPD), to help improve lung function and alleviate shortness of breath. Pursed-lip breathing can be a helpful strategy in specific situations.
D. Use of accessory muscles:
The use of accessory muscles indicates that the person is experiencing increased difficulty in breathing. Accessory muscles, such as the neck and shoulder muscles, are not typically heavily involved in breathing under normal circumstances. When these muscles are visibly working during breathing, it suggests increased respiratory effort and can be a sign of respiratory distress or difficulty.
Correct Answer is A
Explanation
A. Mask:
Silicosis is a lung disease caused by inhaling crystalline silica dust. The primary preventive measure during exposure to silica particles is wearing a mask or respirator. This helps to reduce the inhalation of silica dust, protecting the respiratory system.
B. Gloves: Gloves are typically worn to protect the hands and skin and are not directly related to preventing inhalation of airborne particles.
C. Eye Protection: While eye protection is important in certain occupational settings, it does not specifically address the inhalation of silica particles.
D. Gown: Gowns are worn for protection against contamination but are not directly related to the prevention of occupational lung diseases such as silicosis.
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