The nurse is caring for a client diagnosed with a myocardial infarction (MI) who is reporting severe chest pain.Which interventions should the nurse implement? (Select all that apply.)
Place the client in the supine position.
Administer morphine intramuscularly.
Administer nitroglycerin subcutaneously.
Administer aspirin 325 orally.
Apply oxygen via nasal cannula.
Correct Answer : D,E
Choice D rationale
Administering aspirin 325 orally is important for clients with a myocardial infarction (MI). Aspirin helps to inhibit platelet aggregation, reducing the risk of further clot formation and improving blood flow to the heart. This can significantly decrease mortality and complications associated with MI.
Choice E rationale
Applying oxygen via nasal cannula helps to increase oxygen delivery to the heart and other vital organs during an MI. Ensuring adequate oxygenation can help reduce the extent of myocardial injury and support overall cardiac function during a critical period.
Choice A rationale
Placing the client in a supine position is not appropriate during an MI, as it can increase discomfort and the workload on the heart. Instead, the client should be positioned in a semi-Fowler’s or comfortable position to improve breathing and comfort.
Choice B rationale
Administering morphine intramuscularly is not recommended during an MI. Morphine can be used for pain relief but should be given intravenously to ensure rapid onset and better control over dosing. Intramuscular administration is less effective and can delay pain relief.
Choice C rationale
Administering nitroglycerin subcutaneously is not appropriate. Nitroglycerin is typically given sublingually or intravenously during an MI to provide rapid vasodilation and pain relief. Subcutaneous administration is not effective in this context. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Using the inhaler before engaging in physical activity helps to prevent exercise-induced bronchospasm, which is common in patients with COPD.
Choice B rationale
Skipping doses if symptoms improve is not recommended as it can lead to suboptimal control of COPD and potential exacerbations.
Choice C rationale
Using the inhaler only when experiencing severe symptoms is not effective in managing COPD. Regular use as prescribed helps maintain lung function and prevent exacerbations.
Choice D rationale
Doubling the dose if symptoms do not improve immediately is not safe and can lead to adverse effects. Patients should follow the prescribed dosage and consult their healthcare provider if symptoms persist.
Correct Answer is A
Explanation
Choice A rationale
Continuing to monitor the client's respiratory status is the appropriate action if fluctuation is observed in the suction control chamber. Fluctuations are expected and indicate that the system is functioning correctly.
Choice B rationale
Checking the suction control outlet on the wall is necessary if there are signs that the system is not functioning correctly, but fluctuation itself is not an indication of malfunction.
Choice C rationale
Checking the tubing connections for leaks is important if there is an air leak suspected. However, normal fluctuation does not suggest a leak.
Choice D rationale
Clamping the chest tube is generally avoided unless absolutely necessary as it can lead to the accumulation of air and tension pneumothorax.
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