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

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A reason: Evaluating the eﬀectiveness of opioid analgesics is crucial as pain management is a primary concern for patients experiencing a sickle cell crisis.

Choice B reason: Limiting the patient's intake of oral and IV ﬂuids is not recommended as hydration is important for patients with sickle cell crisis to reduce blood viscosity and improve circulation.

Choice C reason: Teaching the patient about high-protein, high-calorie foods is beneficial for long-term management but is not the immediate nursing intervention during a crisis.

Choice D reason: Encouraging ambulation may be part of recovery but is not the primary intervention during an acute sickle cell crisis due to the risk of pain exacerbation.

A. As soon as the nurse can prepare the client and the administration set B. 2 hours after obtaining blood from the blood bank C. When the client has finished eating his Burger King lunch D. When the client states he is ready to start the infusion

Correct Answer is A

Explanation

Choice A reason: Packed RBCs should be transfused as soon as possible once the nurse has prepared everything necessary for the transfusion.

Choice B reason: Waiting 2 hours after obtaining the blood is not necessary and could delay needed treatment.

Choice C reason: The client's mealtime should not delay the transfusion of blood, which is a time-sensitive medical treatment.

Choice D reason: While the client's readiness is important, it should not unduly delay the transfusion if the client is medically stable and the transfusion is necessary.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which nursing intervention is important when providing care for a patient with sickle cell crisis?

Correct Answer is A

Explanation

A nurse receives a unit of packed RBCs from a blood bank and notes that the time is 11:30. The nurse should begin the infusion at which of the following times?

Correct Answer is A

Explanation

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