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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Discharge teaching for a client with heart failure and reduced ejection fraction should prioritize education about medications that are essential in managing heart failure, such as angiotensin-converting enzyme (ACE) inhibitors.
ACE inhibitors are a class of medications commonly prescribed to heart failure patients with reduced ejection fraction. They work by dilating blood vessels, reducing the workload on the heart, and improving the heart's pumping ability. They are one of the cornerstones of heart failure management and have been shown to reduce symptoms, improve quality of life, and prolong survival in heart failure patients.
Educating the client about the benefits and effects of ACE inhibitors is crucial to promote medication adherence and ensure they understand the importance of taking this medication as prescribed. Common side effects, such as dizziness or dry cough, should also be discussed so the client knows what to expect and when to notify their healthcare provider.
While the other options may also be relevant to a client with heart failure, including starting an aerobic exercise program (A), reducing salt intake (B), and scheduling regular follow-up appointments (C), the immediate priority in discharge teaching should be about the medication regimen and the specific benefits and effects of ACE inhibitors. Other aspects of heart failure management can be addressed during the overall education and follow-up sessions.
Correct Answer is C
Explanation
This statement indicates effective learning because serum cardiac markers are indeed proteins that are released from necrotic (damaged) heart muscle cells when there is myocardial injury, such as in acute coronary syndrome (ACS). These markers are measured in blood tests and help in the diagnosis and assessment of ACS, particularly myocardial infarction (heart attack).
Option A is incorrect because a nitroprusside stress echocardiogram is not used for acute pericarditis. It is a diagnostic test used for evaluating coronary artery disease and ischemia.
Option B is incorrect because a pathologic Q wave is not always present in the electrocardiogram (ECG) of patients with unstable angina. It is a characteristic finding in the ECG of patients with a previous myocardial infarction (heart attack) but may not be present in unstable angina.
Option D is incorrect because coronary angiography is not the only way to confirm the diagnosis of unstable angina. Unstable angina is primarily diagnosed based on the clinical presentation, symptoms, and changes in the ECG. Coronary angiography is an invasive procedure used to visualize the coronary arteries directly and is typically reserved for cases where further assessment and intervention are needed, such as in cases of suspected coronary artery disease.
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