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 D
Explanation
A. Checking blood pressure is important but does not confirm a myocardial infarction. Hypotension or hypertension may be present, but they are not definitive diagnostic tools.
B. Auscultating heart tones can help assess for murmurs or extra sounds, but it cannot diagnose a myocardial infarction.
C. Radiating pain to the left arm is a classic symptom, but not all clients experience it, and its absence does not rule out an MI.
D. Performing a 12-lead ECG is the most important diagnostic tool for identifying myocardial infarction. It provides real-time evidence of ischemic changes, such as ST-segment elevation or depression, confirming or ruling out an MI.
Correct Answer is C
Explanation
A. Deep vein thrombosis is not a known risk factor for obstructive sleep apnea. Sleep apnea is primarily related to airway obstruction rather than circulatory issues.
B. Being female is incorrect. Obstructive sleep apnea is more common in males than females, although postmenopausal women have an increased risk.
C. Obesity is correct. Excess weight, particularly around the neck, increases the risk of airway obstruction during sleep, making obesity a major risk factor for obstructive sleep apnea.
D. Atherosclerosis is not a direct risk factor. However, untreated obstructive sleep apnea can contribute to cardiovascular issues, including hypertension and atherosclerosis.
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