A nurse in the emergency department is attending to a patient exhibiting symptoms of a myocardial infarction. Which of the following actions should the nurse prioritize?
Initiate oxygen therapy.
Obtain a blood sample.
Attach the leads for a 12-lead ECG.
Insert an IV catheter.
The Correct Answer is A
Choice A rationale
The priority action for a nurse when caring for a patient exhibiting symptoms of a myocardial infarction is to initiate oxygen therapy. Oxygen therapy is crucial because it increases the amount of oxygen in the blood, which can help reduce the heart’s workload and relieve pain. This intervention is aimed at reducing myocardial oxygen demand and improving oxygen supply to the ischemic myocardium.
Choice B rationale
Obtaining a blood sample is important as it can help diagnose a myocardial infarction. Blood tests can measure levels of certain proteins, such as troponins, in the bloodstream that can indicate heart muscle damage. However, this is not the immediate priority when compared to initiating oxygen therapy.
Choice C rationale
Attaching the leads for a 12-lead ECG is an important step in the assessment of a patient with suspected myocardial infarction. An ECG can show whether the heart muscle has been damaged and where the damage has occurred. However, this should be done after initiating oxygen therapy.
Choice D rationale
Inserting an IV catheter is a necessary step in the management of a myocardial infarction. It allows for the administration of medications and fluids as needed. However, it is not the first priority. The first priority is to stabilize the patient, which includes initiating oxygen therapy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Lifting a patient under the shoulders by two nurses can be strenuous and may not provide adequate support for a patient who can only partially assist.
Choice B rationale
While this method may work for some patients, it relies heavily on the patient’s strength and ability to push with their feet. If the patient is weak or unable to exert enough force, this method could be unsafe.
Choice C rationale
Using a device to reduce friction is the most appropriate technique when shifting a patient who can only partially assist. Devices such as slide sheets or transfer boards can help move the patient smoothly and with less physical strain on the healthcare provider.
Choice D rationale
Lifting the patient’s legs while the patient uses a trapeze bar requires significant upper body strength from the patient and may not be feasible for all patients.
Correct Answer is A
Explanation
Choice A rationale
The statement “Do you think you could keep him in the nursery for the next feeding so I can get some sleep?” indicates that the mother may be experiencing inhibited parental attachment.
After childbirth, it is normal for a new mother to feel tired and need rest. However, consistently preferring to have the baby cared for in the nursery rather than spending time bonding may suggest inhibited parental attachment.
Choice B rationale
The statement “I don’t need a baby bath demonstration. I know how to do it.”. suggests that the mother is confident in her ability to care for her baby, which is a positive sign of parental attachment. It shows that she is prepared and willing to take on the responsibilities of parenthood.
Choice C rationale
The statement “I wish he had more hair. I will keep a hat on his head until he grows some.”. may indicate a slight disappointment in the baby’s appearance but does not necessarily indicate inhibited parental attachment. It’s common for parents to have certain expectations or hopes about their baby’s appearance.
Choice D rationale
The statement “He’s got my husband’s nose, that’s for sure.”. indicates that the mother is observing and commenting on the baby’s features, which is a positive sign of parental
attachment. Recognizing familial features helps in bonding and forming an attachment with the baby.
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