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.

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A rationale

The oral mucosa is the most reliable indicator of central cyanosis because it reflects the oxygenation of central tissues. When there is a lack of oxygen in the bloodstream, the lips and mucous membranes, such as the oral mucosa, appear blue or cyanotic. This is a clear sign that the central tissues are not receiving adequate oxygenation.

Choice B rationale

The sclera of the eye is not a reliable indicator of central cyanosis. The sclera is white and does not change color due to oxygen levels. Instead, it may become yellow in jaundice or red in inflammation but does not reflect central cyanosis.

Choice C rationale

The ear lobes are peripheral areas and do not reliably indicate central cyanosis. Peripheral cyanosis can occur due to local blood flow issues, and ear lobes can appear blue in cold conditions even when central oxygenation is normal.

Choice D rationale

The soles of the feet, similar to the ear lobes, are peripheral areas and not reliable indicators of central cyanosis. Cyanosis in the feet can result from poor peripheral circulation rather than central hypoxia.

A. Monitoring blood glucose levels more frequently. B. Increasing sodium intake. C. Stopping all other diabetes medications. D. Skipping meals to prevent hyperglycemia.

Correct Answer is A

Explanation

Choice A rationale

Monitoring blood glucose levels more frequently is critical when a client with type 1 diabetes is taking prednisone, as corticosteroids can raise blood glucose levels and potentially cause hyperglycemia.

Choice B rationale

Increasing sodium intake is not recommended for clients with type 1 diabetes and is unrelated to the management of prednisone-induced hyperglycemia.

Choice C rationale

Stopping all other diabetes medications is inappropriate and can lead to uncontrolled blood glucose levels. Adjustments may be needed, but discontinuation is not advised without medical supervision.

Choice D rationale

Skipping meals to prevent hyperglycemia is not a safe practice for clients with type 1 diabetes. Maintaining a balanced diet and monitoring blood glucose levels is essential.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has asthma.Which of the following areas should the nurse evaluate as the most reliable indicator of central cyanosis?

Correct Answer is A

Explanation

A client diagnosed with type 1 diabetes is prescribed prednisone for acute exacerbation of inflammatory bowel disease.Which intervention should the nurse discuss with the client?

Correct Answer is A

Explanation

A nurse in the emergency department is assessing an older adult client who has community-acquired pneumonia.Which of the following findings should the nurse expect?

The nurse is caring for a patient who has a pelvic fracture and an external fixation device.How should the nurse perform assessment of pressure areas and provide skin care to the patient's back and sacrum?

A patient with right lower-lobe pneumonia has been treated with intravenous antibiotics for 3 days.Which assessment data obtained by the nurse indicates that the treatment is effective?

A nurse is providing education to a school-age child who has a new diagnosis of asthma.Which of the following statements should the nurse include in the teaching?

A nurse is caring for a client who has diabetes and plans to administer his regular insulin subcutaneously before he eats breakfast at 08:00 am. After checking the client's morning glucose level, which of the following actions should the nurse take?

To monitor for complications in a patient with type 2 diabetes, which tests will the nurse in the diabetic clinic schedule at least annually? Select all that apply.