Nokea
The nurse is caring for a client diagnosed with a myocardial infarction who is experiencing chest pain. Which interventions should the nurse implement? Select all that apply.
- A. Administer morphine intramuscularly.
- B. Administer an aspirin orally.
- C. Apply oxygen via a nasal cannula.
- D. Place the client in a supine position.
- E. Administer nitroglycerin subcutaneously.
Correct Answer: B,C
Rationale: Aspirin (B) reduces clot formation, and oxygen (C) improves myocardial oxygenation. Morphine IM (A) delays absorption, supine position (D) increases preload, and nitroglycerin SC (E) is incorrect; SL is used.
You may also like to solve these questions
Which risk factor is least likely to have predisposed the client to having a myocardial infarction (MI)?
- A. Smoking cigarettes
- B. Eating fatty foods
- C. Working under emotional stress
- D. Drinking an occasional cocktail
Correct Answer: D
Rationale: Occasional alcohol consumption is the least significant MI risk factor compared to smoking, high-fat diets, and chronic stress.
Which finding would strongly indicate that the cardioversion procedure has been successful?
- A. The client regains consciousness immediately.
- B. Normal sinus cardiac rhythm is restored.
- C. The physical examination of the patient is a second.
- D. The pulse pressure is approximately 40 mm Hg.
Correct Answer: B
Rationale: Restoration of normal sinus rhythm is the primary goal of cardioversion.
The nurse is preparing to administer a beta blocker to the client diagnosed with coronary artery disease. Which assessment data would cause the nurse to question administering the medication?
- A. The client has a BP of 110/70.
- B. The client has an apical pulse of 56.
- C. The client is complaining of a headache.
- D. The client's potassium level is 4.5 mEq/L.
Correct Answer: B
Rationale: Beta blockers slow heart rate; a pulse of 56 (B) may indicate bradycardia, warranting caution. BP 110/70 (A), headache (C), and normal potassium (D) are not contraindications.
Where is the correct placement for the nurse's hands before administering cardiac compressions?
- A. On the lower half of the sternum
- B. On the lower half of the xiphoid process
- C. Over the costal cartilage
- D. Directly above the manubrium
Correct Answer: A
Rationale: Hands are placed on the lower half of the sternum (center of the chest) for effective CPR compressions.
The nurse enters the client's room and notes an unconscious client with an absence of respirations and no pulse or blood pressure. The concept of perfusion is identified by the nurse. Which should the nurse implement first?
- A. Notify the health care provider.
- B. Call a rapid response team (RRT).
- C. Determine the telemetry monitor reading.
- D. Push the Code Blue button.
Correct Answer: D
Rationale: No pulse/respirations indicate cardiac arrest; pushing the Code Blue button (D) initiates the code team. Notifying HCP (A), RRT (B), or checking telemetry (C) delay resuscitation.