A nurse is caring for a patient who has a suspected myocardial infarction. Which of the following should the nurse administer first?
Nitroglycerin
Aspirin
Morphine
Oxygen
The Correct Answer is D
A. Nitroglycerin: Nitroglycerin is used to relieve chest pain by dilating coronary arteries and increasing blood flow. However, in the immediate setting of a suspected MI, oxygen is prioritized to ensure adequate oxygenation.
B. Aspirin: Aspirin is essential in the early treatment of MI to prevent further clot formation by inhibiting platelet aggregation, but oxygen would still come first if the client’s oxygenation is compromised.
C. Morphine: Morphine is used for pain relief and to reduce anxiety and oxygen demand on the heart. However, it is administered after ensuring oxygen supply.
D. Oxygen: Oxygen should be administered first in a suspected myocardial infarction to ensure the heart and tissues receive adequate oxygen, especially if the patient is hypoxic.
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Related Questions
Correct Answer is B
Explanation
A. Malaise: Malaise is a common symptom of infective endocarditis, indicating generalized discomfort or fatigue. However, it is not an immediate life-threatening condition and does not require urgent intervention.
B. Dyspnea: Dyspnea is the priority because it can indicate heart failure or a pulmonary embolism, both of which are serious complications of infective endocarditis. This requires immediate attention and reporting.
C. Fever: Fever is common in infective endocarditis due to the underlying infection. While important, it is expected and usually managed with antipyretics and antibiotics. It is not as urgent as dyspnea.
D. Anorexia: Anorexia is also a common symptom of infective endocarditis but is not an immediate threat to the client’s health.
Correct Answer is B
Explanation
A. Use the diaphragm of the stethoscope to listen to the carotid pulsations. The apical pulse is located at the apex of the heart, not at the carotid artery. This option does not describe the correct location or use of the stethoscope.
B. Count the apical pulsations for a full minute. Counting for a full minute is the correct method for assessing an apical pulse, particularly in clients on cardiovascular medications, to ensure accurate detection of any irregularities.
C. Check the apical pulse with a Doppler device. A Doppler device is typically used to assess peripheral pulses, not the apical pulse. A stethoscope is the appropriate tool for apical pulse assessment.
D. Press the stethoscope firmly against the client's skin. While the stethoscope should be placed firmly enough to hear heart sounds, excessive pressure can distort the sounds and is not necessary.
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