The nurse is admitting a patient who has chest pain. Which assessment data suggest that the pain may be from an acute myocardial infarction?.
The pain has lasted longer than 30 minutes.
The pain increases with deep breathing.
The pain is relieved after the patient takes nitroglycerin.
The pain is reproducible when the patient raises the arms.
The Correct Answer is A
Choice A rationale:
Chest pain that lasts for 20 minutes or more is characteristic of an acute myocardial infarction (AMI)123.
Choice B rationale:
Changes in pain that occur with deep breathing are more typical of musculoskeletal pain or pericarditis.
Choice C rationale:
Stable angina is usually relieved when the patient takes nitroglycerin.
Choice D rationale:
Pain that is reproducible when the patient raises the arms is more typical of musculoskeletal pain.
So, the correct answer is A, after analyzing all choices.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Nitroglycerin can cause side effects such as headache and dizziness, but nausea is not a common side effect.
Choice B rationale:
Nitroglycerin should be stored in a dark, cool place, not in a well-lit room.
Choice C rationale:
This is the correct answer. If chest pain is not relieved 5 minutes after taking nitroglycerin, it is recommended to call an ambulance.
Choice D rationale:
While nitroglycerin is taken when chest pain occurs, it can also be taken prior to activities that might cause chest pain.
So, the correct answer is Choice C, after analyzing all choices.
Correct Answer is ["C","E","G","H"]
Explanation
Choice A rationale:
The apical pulse rate increased from 90/min to 112/min, which is still within the normal range (60-100 beats per minute). Therefore, it’s not a critical change.
Choice B rationale:
The adolescent’s position, supine with legs straight, is the recommended position after cardiac catheterization to prevent bleeding from the femoral artery puncture site.
Choice C rationale:
The pulses of the right extremity decreased to 2+, indicating reduced blood flow. This is a critical finding and should be reported.
Choice D rationale:
The pain increased from 0 to 2 on a scale of 0 to 10. While any increase in pain should be monitored, a score of 2 is not typically considered severe.
Choice E rationale:
The pressure dressing became saturated with bloody drainage, indicating possible bleeding. This is a critical finding and should be reported.
Choice F rationale:
The respiratory rate increased from 16/min to 18/min, which is still within the normal range (12-20 breaths per minute). Therefore, it’s not a critical change.
Choice G rationale:
The blood pressure decreased from 120/76 mm Hg to 100/52 mm Hg. A significant drop in blood pressure can indicate blood loss or shock. This is a critical finding and should be reported.
Choice H rationale:
The right lower extremity became cool and pale, indicating reduced blood flow. This is a critical finding and should be reported.
So, the correct answer is Choice C, E, G, H, after analyzing all choices. .
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