A nurse in the emergency room is caring for a client who presents with manifestations that indicate a myocardial infarction. Which of the following prescriptions should the nurse take first?
Attach the leads for a 12-lead ECG.
Initiate oxygen therapy.
Insert the IV catheter.
Obtain a blood sample.
The Correct Answer is B
The correct answer is: B. Initiate oxygen therapy.
Choice A reason:
Attaching the leads for a 12-lead ECG is crucial for diagnosing a myocardial infarction. However, it is not the first priority. Ensuring the patient receives adequate oxygen is more critical to prevent further myocardial damage. The ECG can be performed immediately after oxygen therapy is initiated to confirm the diagnosis and guide further treatment.
Choice B reason:
Initiating oxygen therapy is the first priority because it ensures that the heart muscle receives adequate oxygen, which is essential to prevent further damage during a myocardial infarction. Oxygen therapy helps to maintain tissue oxygenation and can reduce the extent of myocardial injury. This immediate intervention is vital to stabilize the patient and improve outcomes.
Choice C reason:
Inserting the IV catheter is important for administering medications and fluids. However, it is not the first step. Oxygen therapy takes precedence to ensure the heart and other vital organs receive sufficient oxygen. Once oxygen is administered, IV access can be established to facilitate further treatment.
Choice D reason:
Obtaining a blood sample is necessary for confirming the diagnosis and assessing cardiac markers. However, it is not the immediate priority. Ensuring the patient is oxygenated is more urgent to prevent further myocardial damage. Blood samples can be drawn after oxygen therapy is initiated.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason: This is incorrect. Sinus bradycardia is a slow and regular heart rate that originates from the sinus node. It does not cause irregular palpitations, fatigue, or dizziness, unless the heart rate is very low or the client has underlying cardiac disease.
Choice B reason: This is incorrect. Sinus tachycardia is a fast and regular heart rate that originates from the sinus node. It may cause fatigue or dizziness, but not irregular palpitations or pulse deficit.
Choice C Reason: This is correct. Atrial fibrillation is a fast and irregular heart rate that originates from multiple foci in the atria. It causes irregular palpitations, fatigue, dizziness, and pulse deficit due to ineffective atrial contractions and variable ventricular response.
Choice D Reason: This is incorrect. First-degree AV block is a delay in the conduction of impulses from the atria to the ventricles. It does not affect the heart rate or rhythm, and does not cause any symptoms.
Correct Answer is C
Explanation
Choice A: Removing the elastic bandages is not recommended. These bandages help slow the spread of venom by compressing the lymphatic vessels. Removing them could worsen the envenomation.
Choice B: This is incorrect. The nurse should not discharge the client, as they may develop serious complications from the snake bite, such as swelling, bleeding, infection, or shock. The client should be monitored closely and treated accordingly.
Choice C: This is the correct action. Antivenom treatment is crucial for serious snake envenomation. The sooner it can be administered, the better the outcome.
Choice D: While pain management is important, it is not the priority in this situation. Antivenom takes precedence over pain medication.

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