Which nursing intervention is the highest priority for the client who has had an acute anterior wall myocardial infarction?

Weighing the client at the same time every day

Assuring hourly urine output of at least 25 mL per hour

Maintaining strict bedrest for the first 24 hours

Providing pain control and reducing oxygen demand

Answer and Explanation

The Correct Answer is D

A. Weighing the client at the same time every day:
While daily weights are important for monitoring fluid status (especially in patients at risk for heart failure or fluid retention), it is not the highest priority in the immediate post-MI period. Weighing the client daily can be useful to track fluid accumulation, but addressing the client’s pain management and oxygenation needs takes precedence in the acute phase of an MI.

B. Assuring hourly urine output of at least 25 mL per hour:
Maintaining adequate urine output (typically around 30 mL per hour) is important to assess renal perfusion and fluid balance, especially if the patient is at risk for renal insufficiency or cardiogenic shock. However, this is not the highest priority immediately following an MI. The first priority is managing the oxygen supply to the heart, and addressing pain and reducing myocardial oxygen demand is more crucial in the acute phase to prevent further damage.

C. Maintaining strict bedrest for the first 24 hours:
Strict bedrest may have been a common practice in the past for patients following an MI, but current guidelines emphasize early mobilization and gradual activity as tolerated to prevent complications like deep vein thrombosis (DVT), pulmonary embolism (PE), and muscle deconditioning. While some degree of rest may be necessary immediately after an MI, the priority is to control pain and reduce oxygen demand, not strictly maintain bedrest. Prolonged immobility is not recommended in the modern management of MI unless there are specific contraindications.

D. Providing pain control and reducing oxygen demand is the most critical intervention in the acute phase of an anterior wall MI. Effective pain relief helps to reduce sympathetic stimulation, which decreases heart rate, blood pressure, and myocardial oxygen demand, preventing further myocardial injury and improving outcomes. This is essential for stabilizing the client early in their post-MI course.

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Correct Answer is A

Explanation

A. Suction the client as needed: Suctioning is an essential nursing intervention for clients on mechanical ventilation to maintain effective ventilation. Ventilated clients are at risk for accumulating secretions in the airway, which can obstruct the endotracheal tube or tracheostomy, impairing ventilation and oxygenation. Regular or as-needed suctioning helps to clear secretions, ensuring that the airway remains patent and effective ventilation is maintained. This intervention directly supports the goal of maintaining optimal respiratory function and preventing complications such as atelectasis, pneumonia, or hypoxia.

B. Administer pantoprazole sodium IV: Pantoprazole is a proton pump inhibitor used to decrease stomach acid, typically to prevent stress ulcers in critically ill patients. While this is an important aspect of care for preventing gastrointestinal complications in ventilated patients, it does not directly support ventilation. Therefore, administering pantoprazole is not as directly related to ensuring effective ventilation as suctioning or other respiratory interventions.

C. Apply sequential compression device (SCD): While applying an SCD is important for preventing deep vein thrombosis (DVT) and promoting circulation in immobile patients, it does not directly address the client's ventilation or respiratory function. This intervention is more relevant for preventing venous thromboembolism, not for managing ventilation or airway clearance.

D. Perform oral care with chlorhexidine: Oral care with chlorhexidine is an important practice to reduce the risk of ventilator-associated pneumonia (VAP) and promote overall oral hygiene. It helps decrease the colonization of bacteria in the mouth and reduces the risk of infection. However, while oral care is an essential component of care for a ventilated patient, suctioning directly addresses the goal of effective ventilation by maintaining airway patency, making it the most immediate and relevant intervention for supporting ventilation.

A. severe left sided heart failure and resultant pulmonary edema. B. acute renal failure associated with pyelonephritis. C. a traumatic brain injury with accompanying spinal cord injury. D. hypoxemia, refractory to oxygen therapy.

Correct Answer is D

Explanation

A) Severe left-sided heart failure and resultant pulmonary edema:
While pulmonary edema due to left-sided heart failure can lead to respiratory distress and hypoxemia, it is not characteristic of ARDS. ARDS is a form of non-cardiogenic pulmonary edema, meaning it is not caused by heart failure. In contrast, pulmonary edema from heart failure is typically related to increased pressure in the pulmonary circulation. Therefore, while this client is at risk for respiratory issues, the cause of their pulmonary edema is distinct from the pathology seen in ARDS.

B) Acute renal failure associated with pyelonephritis:
Acute renal failure from pyelonephritis can lead to various complications, including electrolyte imbalances and fluid overload, which may affect respiratory function. However, renal failure by itself is not a direct cause of ARDS. ARDS is typically associated with an inflammatory response to injury or infection in the lungs, not specifically renal issues. While it’s important to monitor for pulmonary complications in critically ill clients, this situation does not directly suggest ARDS.

C) A traumatic brain injury with accompanying spinal cord injury:
Traumatic brain injury (TBI) with spinal cord injury can lead to respiratory compromise, particularly due to neurological impairment affecting the respiratory muscles or the brain's ability to control breathing. However, ARDS is not the most direct consequence of these injuries. ARDS is primarily caused by acute lung injury from direct or indirect insults to the lungs, such as trauma, pneumonia, or sepsis. Although this combination of injuries may cause respiratory distress, it is not a typical cause of ARDS unless there is another underlying lung injury.

D) Hypoxemia, refractory to oxygen therapy:
This is the hallmark sign of ARDS. ARDS is characterized by the development of acute hypoxemia that is resistant to high levels of supplemental oxygen therapy. This refractory hypoxemia is due to widespread inflammation and damage to the alveolar-capillary membrane, leading to impaired gas exchange. In ARDS, the lungs become less compliant, and the ability to oxygenate blood is significantly reduced, even with mechanical ventilation and high levels of oxygen. Therefore, a critically ill client with hypoxemia that does not improve with oxygen therapy would raise suspicion for the development of ARDS.

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Which nursing intervention is the highest priority for the client who has had an acute anterior wall myocardial infarction?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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