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. .
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Checking the blood pressure is not the priority action in this case. The symptoms described may suggest compartment syndrome, which is a medical emergency and requires immediate intervention.
Choice B rationale
The correct action is to notify the health care provider immediately as this may indicate compartment syndrome, a serious complication that can occur after fractures and can lead to permanent damage if not treated promptly.
Choice C rationale
Assessing the incision for redness is not appropriate in this scenario as the symptoms suggest a more severe underlying issue such as compartment syndrome, which requires urgent attention.
Choice D rationale
Repositioning the leg may provide temporary relief but does not address the potential underlying issue of compartment syndrome. The priority is to notify the health care provider.
Correct Answer is A
Explanation
Choice A rationale
Dysuria, or painful urination, is a common symptom of acute cystitis (bladder infection). Clients with acute cystitis often report burning sensations during urination and frequent urges to urinate.
Choice B rationale
Nasal congestion is not a symptom associated with acute cystitis. It is more commonly related to respiratory conditions like colds or allergies.
Choice C rationale
Joint pain is not related to acute cystitis. Joint pain can be associated with various musculoskeletal or autoimmune conditions, but not typically with a bladder infection.
Choice D rationale
Shortness of breath is not a symptom of acute cystitis. This symptom is more relevant to respiratory or cardiovascular conditions, not bladder infections.
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