In planning care for the patient with acute myocardial infarction (AMI), the nurse identifies the highest priority goal of care as which of the following?
Stable ECG rhythm
Ability to verbalize causes and effects of CHD/CAD
Adequate relief of pain
Compliance with prescribed bedrest
The Correct Answer is C
Choice A reason: While a stable ECG rhythm is important, it is not the immediate concern post-AMI.
Choice B reason: The ability to verbalize causes and effects of CHD/CAD is an educational goal, not an immediate care priority.
Choice C reason: Adequate relief of pain is a priority to reduce stress on the heart and improve patient comfort.
Choice D reason: Compliance with prescribed bedrest is important but secondary to pain relief.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: While blood pressure is important, hyperkalemia can cause cardiac dysrhythmias, making the pulse rate the first assessment to ensure the patient's immediate safety.
Choice B reason: Temperature is not directly affected by serum potassium levels and is not the priority in hyperkalemia.
Choice C reason: Respirations are less likely to be affected immediately by hyperkalemia compared to cardiac function.
Choice D reason: A high serum potassium level can lead to life-threatening cardiac arrhythmias, so assessing the pulse rate is the most critical initial action.
Correct Answer is D
Explanation
Choice A reason: While it is useful to know the patient's current pain management strategies, new onset severe back pain could indicate a serious complication such as a spinal fracture or compression, which requires immediate attention.
Choice B reason: Reassuring the patient is not appropriate without further assessment, as new onset severe pain could signify a serious issue that needs to be addressed.
Choice C reason: Suggesting a back brace may be part of the management plan, but it should not precede notifying the healthcare provider of new severe pain.
Choice D reason: Notifying the healthcare provider is the correct action because new onset severe back pain in a patient with multiple myeloma could indicate a serious condition such as a spinal fracture or compression, which requires prompt evaluation and treatment.
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