Exhibits
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
The Correct Answer is []
- Myocardial infarction (MI) is suggested by chest pain radiating to the left arm, diaphoresis, shortness of breath, and epigastric discomfort. The pain described as "sharp, tight, and like indigestion" aligns with cardiac ischemia.
- Administering oxygen helps improve myocardial oxygenation, reducing ischemia.
- Aspirin 325 mg is a standard intervention in suspected MI to prevent further platelet aggregation and reduce the risk of worsening thrombosis in the coronary arteries.
- Monitoring vital signs is critical to assess for hemodynamic stability and signs of worsening cardiac function (e.g., hypotension, tachycardia).
- Monitoring ECG rhythm helps detect ST-elevation or other ischemic changes and assess for life-threatening arrhythmias.
- Morphine may be used for chest pain, but it is now considered secondary to nitroglycerin and beta-blockers.
- Verapamil is a calcium channel blocker used for rate control in arrhythmias but is not first-line for acute MI.
- Platelet count and WBC count are not immediately relevant to MI management.
- Serum glucose levels may be affected by stress but are not a primary concern in acute MI management.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Salt substitutes often contain potassium and should be avoided in hyperkalemia.
B. While assessing other electrolytes may be useful, the immediate concern is evaluating the effects of hyperkalemia on cardiac function.
C. Citrus fruits and bananas are high in potassium and should be avoided when potassium levels are elevated.
D. A 12-lead ECG is essential to assess for cardiac dysrhythmias, as hyperkalemia can cause life-threatening arrhythmias such as peaked T waves and widened QRS complexes.
Correct Answer is A
Explanation
A. In a hypertensive emergency, the goal is to reduce blood pressure gradually over 24 to 48 hours to prevent organ damage while avoiding excessive drops that could cause ischemia.
B. Rapid reduction of blood pressure over a few hours can lead to organ hypoperfusion and ischemic complications, such as stroke or acute kidney injury.
C. A 50% reduction in the first hour is too aggressive and may result in severe adverse effects such as cerebral or myocardial ischemia. The recommended initial reduction is no more than 25% in the first hour.
D. Treating hypertension based solely on symptoms is inappropriate, as some patients may be asymptomatic despite dangerously high blood pressure. The focus is on preventing target organ damage.
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