During the 48 hours after a myocardial infarction (MI), a nurse should assign the highest priority to monitoring the patient for what complication?

Dysrhythmias

Anxiety and fear

Metabolic acidosis

Medication side effects

Answer and Explanation

The Correct Answer is A

During the 48 hours after a myocardial infarction (MI), the highest priority for monitoring the patient is for dysrhythmias. After an MI, the heart's electrical system can be disrupted, leading to various types of abnormal heart rhythms (dysrhythmias). Dysrhythmias can be life-threatening and require prompt recognition and intervention.

Other options:

B) Anxiety and fear: Anxiety and fear are common emotional responses after an MI, but they are not the highest priority for monitoring during the immediate post-MI period. Emotional support and counseling are essential, but they do not require continuous monitoring.

C) Metabolic acidosis: Metabolic acidosis is not a common complication of an acute MI. It may occur in certain situations, such as when there is inadequate perfusion to tissues, but it is not the highest priority during the immediate post-MI period.

D) Medication side effects: Monitoring for medication side effects is important but is not the highest priority during the immediate post-MI period. Many patients will receive medications to manage pain, reduce clot formation, and stabilize their heart function. The nurse should monitor for side effects but not as a higher priority compared to dysrhythmias.

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Correct Answer is A

Explanation

In a patient with acute decompensated heart failure (ADHF), the priority nursing assessment is to auscultate lung sounds. ADHF is characterized by the sudden worsening of heart failure symptoms, which may include pulmonary congestion and fluid accumulation in the lungs. Assessing lung sounds helps to identify signs of pulmonary edema, which is a serious complication of ADHF.

The nurse should listen for crackles or rales, which are abnormal lung sounds caused by the presence of fluid in the alveoli. These findings suggest that the patient is experiencing fluid overload and inadequate gas exchange in the lungs. Prompt recognition of pulmonary edema allows for early intervention, such as administering diuretics or other medications, to relieve fluid overload and improve respiratory function.

While the other options (B) Facial swelling, (C) Level of anxiety, and (D) Intake and output, are important assessments in a patient with heart failure, they are not the priority in a patient with manifestations of acute decompensated heart failure. The priority is to assess for signs of respiratory

distress and pulmonary congestion, as these can quickly lead to respiratory failure and life threatening complications.

A. Perform synchronized cardioversion. B. Start cardiopulmonary resuscitation (CPR). C. Apply supplemental O₂ via non-rebreather mask. D. Give atropine per agency dysrhythmia protocol.

Correct Answer is B

Explanation

The patient is apneic (not breathing) and has no palpable pulses, indicating a cardiac arrest or severe cardiovascular compromise. In this situation, the most appropriate action for the nurse to take next is to start cardiopulmonary resuscitation (CPR) immediately.

CPR is a life-saving procedure that combines chest compressions and rescue breaths to circulate oxygenated blood to vital organs when the heart is not effectively pumping. In the case of cardiac arrest, early initiation of CPR is critical to improve the chances of survival and minimize potential brain damage.

The heart monitor shows sinus tachycardia, rate 132, which suggests that the electrical impulses are reaching the heart, but the heart is not effectively pumping blood due to the lack of a palpable pulse. This condition requires immediate intervention with CPR rather than other treatments such as synchronized cardioversion (option A) or administering atropine (option D).

While applying supplemental oxygen via a non-rebreather mask (option C) is generally important in many emergency situations, it is not the immediate priority when a patient is apneic and has no palpable pulses. In such cases, CPR takes precedence to restore circulation and maintain oxygen delivery to the body's vital organs.

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During the 48 hours after a myocardial infarction (MI), a nurse should assign the highest priority to monitoring the patient for what complication?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient with manifestations of acute decompensated heart failure (ADHF). What is the priority nursing assessment?

Correct Answer is A

Explanation

A patient is apneic and has no palpable pulses. The heart monitor shows sinus tachycardia, rate 132. What action should the nurse take next?

Correct Answer is B

Explanation

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The nurse teaches a student nurse about diagnostic studies used for acute coronary syndrome. Which statement made by the student nurse indicates effective learning?

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