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. Brain Natriuretic Peptide (BNP) is a marker for heart failure, not the primary diagnostic test for myocardial infarction (MI).
B. Total Lactate Dehydrogenase (LDH) was historically used but is not specific for MI and has been replaced by troponin testing.
C. Troponin is correct. Cardiac-specific troponins (Troponin I and Troponin T) are the gold standard for detecting myocardial injury. Elevated levels indicate myocardial damage and are crucial for diagnosing MI.
D. Creatinine is important for assessing kidney function but is not a marker for myocardial infarction.
Correct Answer is C
Explanation
A. Immediately notify the provider . A rise in the water seal chamber with inspiration (tidaling) is a normal finding, indicating proper function of the chest drainage system. There is no need for immediate provider notification.
B. Clamp the chest tube near the water seal . Clamping the chest tube can lead to a tension pneumothorax by trapping air inside the pleural space. This action is only done temporarily for specific indications, such as assessing for an air leak or changing the drainage system.
C. Continue to monitor the client . Tidaling (fluctuation of water with inspiration and expiration) is expected in the water seal chamber. The nurse should continue to monitor for any sudden cessation of tidaling (which may indicate obstruction) or continuous bubbling (which may indicate an air leak).
D. Reposition the client toward the left side . Position changes do not affect normal tidaling in a functioning chest tube system. However, frequent repositioning is encouraged to promote lung expansion.
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