The nurse is providing care for a client admitted to rule out a myocardial infarction who is experiencing chest pain while walking to the bathroom. Which action should the nurse implement first?
Obtain a STAT electrocardiogram
Have the client sit down immediately
Assess the client's vital signs
Administer sublingual nitroglycerin
The Correct Answer is B
A. Obtaining an ECG is important but not the first action. The priority is to stop activity, as exertion can worsen myocardial oxygen demand.
B. Having the client sit down immediately is correct. Stopping activity reduces cardiac workload and oxygen demand, preventing further ischemia or infarction.
C. Assessing vital signs is important but should follow stopping activity. Chest pain requires immediate action to reduce cardiac strain.
D. Administering sublingual nitroglycerin is appropriate but should be done after ensuring the client is seated. This prevents hypotension and syncope from occurring while standing.
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Related Questions
Correct Answer is C
Explanation
A. Warfarin is commonly prescribed for long-term anticoagulation to prevent future clot formation. This statement is correct and does not require further teaching.
B. A Heparin infusion does not dissolve existing clots but prevents them from enlarging and new clots from forming, making this statement accurate.
C. The purpose of the Inferior Vena Cava (IVC) filter is to trap emboli from deep vein thrombosis (DVT) before they reach the lungs, not to prevent DVT formation. This statement is incorrect and requires further teaching.
D. An embolectomy is a surgical procedure to remove a pulmonary embolism, making this statement correct.
Correct Answer is C
Explanation
A. Hypertension is not a direct risk factor for COPD. However, COPD and hypertension can coexist, especially in smokers.
B. Being male was once associated with a higher COPD prevalence, but COPD affects both sexes, especially as smoking habits have become more equal.
C. Alpha-1 Antitrypsin (AAT) deficiency is correct. AAT deficiency is a genetic disorder that leads to early-onset emphysema, even in non-smokers. It impairs the lungs' ability to protect themselves from enzymatic damage.
D. History of pulmonary embolism is not a primary risk factor for COPD, though lung damage from recurrent emboli can contribute to respiratory issues.
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