A patient has been admitted to the coronary care unit (CCU) with an ST-segment-elevation myocardial infarction (STEMI). The patient is restless, anxious, has a blood pressure of 86/40 mm Hg, and a heart rate of 132 beats/min.

What is the priority problem for this patient?

Anxiety

Acute pain

Decreased cardiac output

Stress management

Answer and Explanation

The Correct Answer is C

Choice A rationale
Anxiety is a common response to the stress of hospitalization and illness, especially in the context of a serious condition like ST-segment-elevation myocardial infarction (STEMI).
However, while anxiety can exacerbate physical symptoms and should be addressed, it is not the primary problem in this scenario.
Choice B rationale
Acute pain is a common symptom of STEMI, as the heart muscle is deprived of oxygen. However, the patient’s blood pressure and heart rate readings suggest a more immediate concern related to the cardiovascular system.
Choice C rationale
Decreased cardiac output is likely the priority problem for this patient. The patient’s low blood pressure (86/40 mm Hg) and high heart rate (132 beats/min) suggest that the heart is not pumping enough blood to meet the body’s needs, which is a direct consequence of the STEMI1. This can lead to organ failure and other serious complications if not addressed promptly.
Choice D rationale
Stress management is an important aspect of long-term care for patients with heart disease, as chronic stress can contribute to further heart damage. However, in the acute phase of a STEMI, the focus is on stabilizing the patient’s condition and preventing complications.

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Correct Answer is B

Explanation

Choice A rationale
Administering Lasix (a diuretic) would not be the most immediate intervention for a patient experiencing increased chest pain after taking sublingual nitroglycerin. Lasix is used to treat fluid retention (edema) and swelling caused by congestive heart failure, liver disease, kidney disease, and other medical conditions. It works by causing the kidneys to get rid of unneeded water and salt from the body into the urine.
Choice B rationale
The most important nursing intervention for a patient experiencing increased chest pain after taking sublingual nitroglycerin would be to increase myocardial oxygenation. This can be achieved by administering supplemental oxygen and ensuring the patient is in a position that maximizes respiratory efficiency (such as semi-Fowler’s position). This intervention addresses the immediate life-threatening situation of myocardial ischemia.
Choice C rationale
Obtaining one hour of echocardiogram readings would not be the most immediate intervention for a patient experiencing increased chest pain after taking sublingual nitroglycerin. While an echocardiogram can provide valuable information about the structure and function of the heart, it is not the first step in managing acute chest pain.
Choice D rationale
Decreasing the patient’s anxiety is an important aspect of care, but it is not the most immediate intervention for a patient experiencing increased chest pain after taking sublingual nitroglycerin. The priority is to address the physical cause of the chest pain.

A. Sinus tachycardia at a rate of 110 beats/min. B. Blood pressure increase from 134/68 to 150/80 mm Hg. C. The patient reports feeling tired. D. Inversion of T waves on the electrocardiogram.

Correct Answer is D

Explanation

Choice A rationale
Sinus tachycardia at a rate of 110 beats/min is a normal response to exercise. During a stress test, the heart rate will naturally increase as the body’s demand for oxygen increases. A heart rate of 110 beats/min is within the expected range during moderate exercise.
Choice B rationale
An increase in blood pressure from 134/68 to 150/80 mm Hg is a normal response to exercise. During a stress test, blood pressure will naturally rise as the heart works harder to pump blood to the muscles. This increase is within the expected range during moderate exercise.
Choice C rationale
Feeling tired during a stress test on a treadmill is a normal response to exercise. Fatigue can occur as the body’s energy stores are used up during physical activity. However, if the patient reports extreme fatigue or other symptoms such as chest pain or shortness of breath, it may indicate a problem.
Choice D rationale
Inversion of T waves on the electrocardiogram during a stress test is a sign of myocardial ischemia, a condition in which the heart muscle is not getting enough oxygen. This could indicate the presence of significant coronary artery disease and is a finding that would necessitate immediate action.

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A patient has been admitted to the coronary care unit (CCU) with an ST-segment-elevation myocardial infarction (STEMI). The patient is restless, anxious, has a blood pressure of 86/40 mm Hg, and a heart rate of 132 beats/min. What is the priority problem for this patient?

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

During a stress test on a treadmill, which observation by the nurse would necessitate immediate action?

Correct Answer is D

Explanation

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A patient has been admitted to the coronary care unit (CCU) with an ST-segment-elevation myocardial infarction (STEMI). The patient is restless, anxious, has a blood pressure of 86/40 mm Hg, and a heart rate of 132 beats/min.

What is the priority problem for this patient?