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 C
Explanation
A. Kyphosis and clubbing of the fingers:
Kyphosis refers to an excessive forward curvature of the spine, which is not directly related to diminished breath sounds. Clubbing of the fingers is often associated with chronic respiratory conditions, but it is not directly linked to the finding of diminished breath sounds.
B. Dyspnea and hypoxemia:
Dyspnea (shortness of breath) and hypoxemia (low oxygen levels in the blood) are common symptoms in COPD, but diminished breath sounds may indicate an additional concern, such as pneumothorax or other complications.
C. Sepsis and pneumothorax:
Diminished breath sounds can be a sign of pneumothorax, a condition where air accumulates in the pleural space, leading to lung collapse. Sepsis is a risk in clients with COPD due to the potential for respiratory infections. Monitoring for these complications is crucial.
D. Bradypnea and pursed-lip breathing:
Bradypnea (slow breathing) and pursed-lip breathing are coping mechanisms that individuals with COPD may use to manage their breathing difficulties. While they are relevant in the context of COPD, they are not directly associated with the finding of diminished breath sounds.
Correct Answer is C
Explanation
A. Partial non-rebreathing mask:
This mask delivers higher concentrations of oxygen than a nasal cannula. It has a reservoir bag that allows the client to rebreathe some exhaled air, increasing the oxygen concentration delivered. However, it may not be necessary for a client with mild shortness of breath and slightly reduced oxygen saturation.
B. Simple (Oxy Plus) mask:
The simple mask provides a higher concentration of oxygen than a nasal cannula but lacks the reservoir bag found in the non-rebreathing mask. It is generally used for moderate oxygen needs. However, it might be more than what is required for a client with mild shortness of breath and slightly reduced oxygen saturation.
C. Nasal cannula:
Nasal cannulas are commonly used for clients with mild respiratory distress. They deliver a lower to moderate concentration of oxygen and are well-tolerated by most clients. They are suitable for individuals with mild shortness of breath and can be adjusted based on the required flow rate.
D. Non-rebreathing mask:
The non-rebreathing mask provides the highest concentration of oxygen among the options listed. It includes a reservoir bag to deliver a higher oxygen concentration. It is typically reserved for clients with higher oxygen requirements. For a client with mild shortness of breath and slightly reduced oxygen saturation, this may be more than necessary.
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