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 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.
Correct Answer is A
Explanation
A 3 lb weight gain in a short period, especially overnight, is indicative of fluid overload in a client with end-stage kidney disease receiving hemodialysis. Hemodialysis is performed to remove excess fluid and waste products from the body. If the client is experiencing fluid overload, it means that their body is retaining more fluid than it should, and this can lead to complications such as pulmonary edema, heart failure, and other cardiovascular problems. The nurse should identify this finding as an indication of potential fluid overload and report it to the healthcare provider for further evaluation and intervention.
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