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 ["24"]
Explanation
- Step 1: Identify the prescribed dose in units per hour. The client is scheduled to receive 1,200 units/hr of heparin.
- Step 2: Identify the concentration of the available solution. The available solution contains 25,000 units of heparin in 500 mL D5W.
- Step 3: Calculate the volume of solution needed to deliver the required dose. We can set up a proportion to solve for this:
- 25,000 units is to 500 mL as 1,200 units is to X mL.
- In other words, 25,000 units : 500 mL = 1,200 units : X mL.
- Step 4: Solve for X using cross-multiplication and division:
- Cross-multiplication gives us: 25,000 units × X mL = 1,200 units × 500 mL.
- Simplifying this gives us: 25,000X = 600,000.
- Dividing both sides by 25,000 gives us: X = 600,000 ÷ 25,000.
- Calculating the division gives us: X = 24.
Set the IV pump to deliver 24 mL/hr to administer the required dose of 1,200 units/hr.
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.
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