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. The client with a history of a myocardial infarction who has a p wave before every QRS complex.
This may indicate a heart block, which requires attention. However, it's not an immediate life-threatening situation.
B. The client diagnosed with heart failure who has bilateral 2+ pitting pedal edema.
Bilateral pitting pedal edema is a sign of fluid overload, which is concerning and requires attention.
C. The client with sinus bradycardia (HR 56/min) that is reporting fatigue.
While bradycardia and fatigue are concerns, they might not be as urgent as the client with fluid overload.
D. The client diagnosed with coronary artery disease who is now reporting new onset of severe indigestion.
New onset of severe indigestion in a client with coronary artery disease raises concern for a potential cardiac event, and this should be addressed promptly.
Correct Answer is ["125"]
Explanation
To calculate the amount of mL that the client should receive, we need to use the formula:
mL = (g * 5 mL) / mg
where g is the ordered dose of the medication, mg is the concentration of the medication, and mL is the volume of the solution.
Plugging in the given values, we get:
mL = (4 g * 5 mL) / 160 mg
Simplifying, we get:
mL = 0.125 g/mL
Multiplying by 1000 to convert grams to milligrams, we get:
mL = 125 mg/mL
Therefore, the client should receive 125 mL of the solution.
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