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 ["A","B","C","D","E"]
Explanation
A. Osler Nodes – These are tender, painful nodules on the fingers and toes, a classic sign of infective endocarditis.
B. Splinter Hemorrhages – Tiny blood clots under the fingernails occur due to microembolization from infected heart valves.
C. Petechial Hemorrhaging – Small red or purple spots on the skin or mucous membranes occur due to embolization of infected material.
D. Janeway Lesions – Painless, flat, red spots on the palms and soles caused by microemboli.
E. Fever with Chills – A common systemic symptom due to infection and inflammation.
Correct Answer is D
Explanation
A. A pressure dressing is already in place following the procedure, and additional dressing is not the priority. Instead, monitoring the TR band for bleeding or complications is essential.
B. Having the client flex and extend the right wrist is not recommended immediately after a radial artery catheterization, as movement can increase the risk of bleeding.
C. Oxygen therapy is not routinely required unless the client has hypoxia or respiratory distress.
D. Assessing the trans-radial (TR) band is the priority to ensure proper hemostasis at the puncture site, monitor for bleeding, and check distal circulation to the hand.
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