A nurse in the emergency department is caring for a 52-year-old male client experiencing chest pain. Below are the exhibits to guide your answer:
Complete the diagram by dragging from the choices below to specify:
- The condition the client is most likely experiencing.
- Two actions the nurse should take.
- Two parameters the nurse should monitor to assess the client's progress.
The Correct Answer is []
Condition: Myocardial infarction.
2 actions:
Administer oxygen via nasal cannula 2 L/min,
Request a prescription for aspirin 325 mg.
2 parameters:
Vital signs,
Electrocardiogram (ECG) rhythm.
Rationale for correct condition: A myocardial infarction is indicated by the elevated troponin levels and ST elevation on the ECG. The client’s symptoms of chest pain, elevated heart rate, and low oxygen saturation support this diagnosis. Prompt identification and treatment are crucial to minimize heart damage. The medical history of hypertension and coronary artery disease increases the likelihood. Immediate interventions can significantly improve outcomes.
Rationale for actions: Administer oxygen to improve oxygenation and reduce myocardial workload. Requesting aspirin helps prevent further clot formation. Morphine alleviates pain but may obscure symptoms, making it less urgent. Nitroglycerin relieves chest pain by vasodilation but is secondary. Verapamil is less immediate for acute myocardial infarction management. Vital signs reflect hemodynamic status and response to treatment. ECG rhythm detects ongoing ischemia or arrhythmias. Monitoring WBC count is less relevant acutely. Platelet count is stable; not the focus in immediate management.
Rationale for parameters: Vital signs ensure hemodynamic stability and detect hypotension or shock. ECG rhythm monitors arrhythmias and ongoing ischemia, critical in myocardial infarction. WBC count indicates infection or inflammation, less immediate concern. Platelet count is important for bleeding risks but less immediate. Chronic stable angina presents with predictable, non-severe pain. Ischemic stroke symptoms differ; focus on neurological deficits. Cardiogenic shock would present with more severe hypotension and signs of organ failure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
A puncture or rupture of the lung is typically associated with a pneumothorax, not flail chest. Pneumothorax occurs when air leaks into the space between the lung and the chest wall.
Choice B rationale
The presence of air or gas in the pleural cavity is known as pneumothorax. Flail chest, however, is characterized by multiple rib fractures.
Choice C rationale
Flail chest occurs when multiple adjacent ribs are fractured in multiple places, creating a free-floating segment of the chest wall. This condition is serious and often results from blunt chest trauma.
Choice D rationale
The collapse of the lung is known as atelectasis or pneumothorax, not flail chest. Flail chest specifically refers to the detachment of a segment of the rib cage.
Correct Answer is C
Explanation
Choice A rationale
Hypokalemia is a potential concern with diuretic therapy, but not with hypertonic saline solution (3% NaCl) administration for hyponatremia.
Choice B rationale
Hypovolemia is less likely to occur with hypertonic saline infusion. The main concern is overcorrection leading to fluid overload.
Choice C rationale
Fluid overload is a significant risk when administering hypertonic saline (3% NaCl). Nurses should closely monitor for signs of fluid overload, such as edema, crackles in the lungs, and increased blood pressure.
Choice D rationale
Hypernatremia is a possible complication of hypertonic saline administration, but it is not as immediate a concern as fluid overload. Monitoring for fluid overload should take precedence.
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