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. .

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Correct Answer is C

Explanation

Choice C rationale

Administering another nitroglycerin tablet is appropriate if the client's chest pain has not been fully relieved after the initial dose. Nitroglycerin helps to dilate blood vessels, improving blood flow to the heart and relieving angina. A second dose can be given if the pain persists, following the protocol for managing chest pain.

Choice A rationale

Obtaining an ECG is important for diagnosing and monitoring cardiac conditions; however, in this immediate context, further pain relief takes precedence. After ensuring pain relief, an ECG can be performed to assess the client's cardiac status.

Choice B rationale

Calling the Rapid Response Team is unnecessary if the client’s chest pain severity has already decreased. The priority should be to continue managing the chest pain with additional nitroglycerin if needed and monitoring the client's response.

Choice D rationale

Initiating a peripheral IV might be required for administering medications or fluids, but it is not the immediate action needed in this scenario. The priority is to provide additional pain relief with nitroglycerin.

A. Dorsalis pedis pulse cannot be located with a doppler and increasing pain. B. Pain relieved after administering 4mgs of hydromorphone. C. Generalized weakness and increasing sensitivity to touch. D. Localized edema and discoloration of the affected limb.

Correct Answer is A

Explanation

Choice A rationale

The inability to locate a dorsalis pedis pulse and increasing pain indicate compromised circulation, which requires immediate attention to prevent complications.

Choice B rationale

Pain relieved after administering medication indicates effective pain management, which is not an urgent issue to report immediately.

Choice C rationale

Generalized weakness and increasing sensitivity to touch can be concerning but are not as urgent as signs of compromised circulation.

Choice D rationale

Localized edema and discoloration are expected findings in a fracture and are not as urgent as an absent pulse. .

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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.)

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