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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:Labeling the feeding bag with the date and time is important for tracking, but it is not the first action to take. The priority is to ensure that the NG tube is correctly placed and the stomach contents can be aspirated to verify placement before administering the feeding.
Choice B reason:Aspirating the client's stomach contents is the first action the nurse should take. This is to confirm the correct placement of the NG tube to prevent complications such as aspiration pneumonia. It is a critical step before starting any enteral feeding.
Choice C reason: Hanging the feeding bag 30 cm (12 inches) above the client is necessary for gravity feeding, but it comes after verifying the NG tube placement through aspiration of stomach contents.
Choice D reason:Warming the feeding to room temperature is a comfort measure and helps to prevent gastrointestinal discomfort. However, it is not the first action to take. The priority is to check the tube placement.
Correct Answer is D
Explanation
Choice A reason: Morphine is used to manage pain and anxiety after the initial acute phase of an MI.
Choice B reason: Aspirin is used in the initial treatment of MI to prevent further clot formation but is not primarily for pain and anxiety management.
Choice C reason: Oxygen is administered during the acute phase of an MI if the patient is hypoxic.
Choice D reason: Nitroglycerin is used to manage chest pain in MI but is not the primary medication for general pain and anxiety post-acute phase.
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