A nurse is caring for a client who reports a new onset of severe chest pain. Which of the following actions should the nurse take to determine if the client is experiencing a myocardial infarction?
Perform a 12-lead ECG
Determine if pain radiates to the left arm
Check the client's blood pressure
Auscultate heart tones
The Correct Answer is A
Choice A reason: A 12-lead ECG can reveal changes in the ST segment, T wave, and QRS complex, which are indicative of myocardial ischemia, injury, or infarction. It is the first line diagnostic test that needs to be recorded within 10 minutes after the first medical contact in cases of suspected acute coronary syndromes.
Choice B reason: While pain radiating to the left arm can be a symptom of MI, it is not a definitive diagnostic action. It is a common symptom but can also be associated with other conditions.
Choice C reason: Checking the client's blood pressure is important in the overall assessment of the client's cardiovascular status but does not specifically diagnose MI. Blood pressure can be normal, elevated, or decreased in the case of MI.
Choice D reason: Auscultating heart tones can provide information about the presence of murmurs, gallops, or rubs, but it is not a specific diagnostic action for MI. Heart sounds may be normal during an MI.
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Related Questions
Correct Answer is B
Explanation
Choice A reason: Heparin and warfarin do not work together to dissolve clots. Heparin acts quickly to prevent further clotting, while warfarin is used for long-term anticoagulation.
Choice B reason: Warfarin's onset of action is slow, requiring several days to reach therapeutic levels. During this time, heparin is used to provide immediate anticoagulation to prevent new clot formation or the growth of existing clots.
Choice C reason: IV heparin does not increase the effects of warfarin. They are used concurrently because of the delay in warfarin's onset of action.
Choice D reason: It is not appropriate to discontinue heparin immediately after starting warfarin due to the delay in warfarin reaching therapeutic levels. The overlap is necessary to ensure continuous anticoagulation.
Correct Answer is C
Explanation
Choice A reason: Metabolic alkalosis would present with an elevated pH and HCO3, which is not the case here.
Choice B reason: Respiratory alkalosis would present with an elevated pH and a decreased PaCO2, which is not the case here.
Choice C reason: Metabolic acidosis is indicated by a decreased pH and HCO3, which aligns with the ABG findings provided.
Choice D reason: Respiratory acidosis would present with a decreased pH and an elevated PaCO2, which is not the case here.
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