A patient is experiencing classic signs and symptoms of acute coronary artery disease.
What should be the nurse’s priority intervention?
Educate the patient about the pathophysiology causing the symptoms.
Apply supplemental Oxygen as ordered.
Administer sublingual nitroglycerin as ordered.
Remain with the patient to decrease anxiety.
The Correct Answer is C
Choice A rationale:
While educating the patient about the pathophysiology of acute coronary artery disease (ACAD) is important, it is not the priority intervention during an acute episode.
The patient is likely experiencing significant discomfort and anxiety, and their ability to process information may be impaired.
Providing immediate relief of symptoms and stabilizing the patient's condition take precedence over education at this time.
Choice B rationale:
Supplemental oxygen may be beneficial for patients with ACAD, but it is not the highest priority intervention.
Oxygen therapy can improve oxygen saturation levels in the blood, but it does not directly address the underlying issue of coronary artery occlusion.
It is important to administer nitroglycerin first to dilate the coronary arteries and improve blood flow to the heart muscle.
Choice C rationale:
Sublingual nitroglycerin is a vasodilator that relaxes and widens blood vessels, improving blood flow to the heart muscle.
It is a first-line medication for the treatment of acute angina (chest pain) and is often used in the setting of ACAD.
Nitroglycerin can rapidly relieve chest pain and other symptoms of ischemia, such as shortness of breath, and can help prevent further damage to the heart muscle.
Choice D rationale:
Staying with the patient to decrease anxiety is important, but it is not the priority intervention.
While providing emotional support can help to calm the patient and reduce stress, it does not directly address the underlying issue of myocardial ischemia.
It is crucial to administer nitroglycerin to dilate the coronary arteries and improve blood flow to the heart muscle.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Incorrect. PVCs are not caused by a malfunctioning SA node. The SA node is responsible for initiating the normal heartbeat, while PVCs originate from the ventricles. The underlying cause of PVCs can vary, but it's not directly related to SA node dysfunction. Choice C rationale:
Incorrect. Ventricular tachycardia (VT) is a rapid heart rhythm originating from the ventricles, typically defined as three or more consecutive PVCs. Two PVCs in a row are usually classified as a couplet, not VT.
Choice D rationale:
Incorrect. While PVCs are often harmless, they can sometimes be associated with underlying heart disease or lead to complications, especially if they are frequent or occur in specific patterns. Therefore, careful assessment and potential treatment are necessary.
Choice B rationale:
Correct. Treatment for PVCs is generally only recommended if the patient experiences concerning symptoms or if the PVCs are associated with a risk of developing more serious arrhythmias. Additionally, the QRS complex on the EKG/ECG should be evaluated. A narrow QRS complex during PVCs typically suggests a less concerning origin within the ventricles, while a wide QRS complex may indicate a higher risk of complications.
Correct Answer is ["A","B","D"]
Explanation
Choice A rationale:
Pain relief is a primary benefit of morphine administration in the setting of myocardial infarction.
Pain can trigger a stress response, leading to increased heart rate, blood pressure, and myocardial oxygen demand.
Morphine effectively reduces pain, thereby lessening the stress response and its detrimental effects on the heart.
This helps to minimize myocardial ischemia and potential further damage to the heart muscle.
Pain control also improves patient comfort and overall well-being, which can indirectly contribute to better cardiac outcomes.
Choice B rationale:
Sedation is another important benefit of morphine in this context.
It promotes rest and relaxation, which can lower heart rate, blood pressure, and myocardial oxygen demand.
This is crucial for patients with myocardial infarction, as their hearts require reduced workload to heal and recover.
Sedation also helps to alleviate anxiety and agitation, which can further strain the heart.
By inducing a state of calmness, morphine can indirectly protect the heart from additional stress.
Choice C rationale:
While morphine does have diuretic effects, increasing urinary output is not a primary goal in the management of myocardial infarction.
In fact, excessive diuresis could potentially lead to dehydration and hypotension, which could be detrimental to cardiac function.
Therefore, while morphine may slightly increase urine output, this is not a major reason for its use in this setting.
Choice D rationale:
Decreasing myocardial demand is a key benefit of morphine administration in patients with myocardial infarction.
Morphine achieves this by:
Reducing pain and the associated stress response
Promoting sedation and relaxation
Diminishing anxiety and agitation
Exerting a direct vasodilatory effect on blood vessels
This collective action of morphine leads to a decrease in heart rate, blood pressure, and the heart’s overall workload.
As a result, the heart requires less oxygen and experiences reduced strain, allowing for better healing and recovery following a myocardial infarction.
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