SNLE Question Discussion -Training4Nurse Academy

What is the first intervention for a client experiencing MI? 

Administer oxygen Administering supplemental oxygen to the client is the first priority of care. The myocardium is deprived of oxygen during an infarction, so additional oxygen is administered to assist in oxygenation and prevent further damage. Morphine and nitro are also used to treat MI, but they’re more commonly administered after the oxygen. An ECG is the most common diagnostic tool used to evaluate MI

Question : A 60-year-old comes into the emergency department with crushing substernal
chest pain that radiates to the shoulder and left arm. The admitting diagnosis is acute
myocardial infarction (MI). Admission prescriptions include oxygen by nasal cannula at
4 L/min, complete blood count (CBC), a chest radiograph, a 12-lead electrocardiogram
(ECG), and 2 mg of morphine sulfate given IV. The nurse should first:
 

 1. Administer the morphine.
2. Obtain a 12-lead ECG.
3. Obtain the blood work.
4. Prescribe the chest radiograph 

Answer : A 

Rational : Although obtaining the ECG, chest radiograph, and blood work are all
important, the nurse's priority action should be to relieve the crushing chest pain.
Therefore, administering morphine sulfate is the priority action.

19. While caring for a client who has sustained a myocardial infarction (MI), the
nurse notes eight premature ventricular contractions (PVCs) in 1 minute on the cardiac
monitor. The client is receiving an IV infusion of 5% dextrose in water (D5W) and
oxygen at 2 L/min. The nurse's first course of action should be to:
1. Increase the IV infusion rate.
2. Notify the physician promptly.
3. Increase the oxygen concentration.
4. Administer a prescribed analgesic.

2. PVCs are often a precursor of life-threatening arrhythmias, including
ventricular tachycardia and ventricular fibrillation. An occasional PVC is not
considered dangerous, but if PVCs occur at a rate greater than five or six per minute in
the post-MI client, the physician should be notified immediately. More than six PVCs
per minute is considered serious and usually calls for decreasing ventricular irritability
by administering medications such as lidocaine hydrochloride. Increasing the IV
infusion rate would not decrease the number of PVCs. Increasing the oxygen
concentration should not be the nurse's first course of action; rather, the nurse should
notify the physician promptly. Administering a prescribed analgesic would not decrease
ventricular irritability.

Question : A client is diagnosed with an acute myocardial infarction and is receiving tissue plasminogen activator, alteplase (Activase, tPA). Which of the following is a priority nursing intervention?
 

A.Monitor for renal failure.

B.Monitor psychosocial status.

C.Monitor for signs of bleeding.

D.Have heparin sodium available.

Correct Answer :  C.Monitor for signs of bleeding.

Rational :  Tissue plasminogen activator is a thrombolytic. Hemorrhage is a complication of any type of thrombolytic medication. 

The client is monitored for bleeding. 

Monitoring for renal failure and monitoring the client’s psychosocial status are important but are not the most critical interventions.

Heparin is given after thrombolytic therapy, but the question is not asking about follow-up medications.

Question : A 48-year-old foreman at a local electric company comes to the hospital complaining of severe substernal chest pain radiating down his left arm. He's admitted to the coronary care unit (CCU) with a diagnosis of myocardial infarction (MI). 

Which of the following nursing assessments is a priority on admission to the CCU?

A) Begin electrocardiogram (ECG) monitoring
B) Obtain information about family history of heart disease
C) Auscultate lung fields
D) Determine if the patient smokes

Correct Answer is : A 

Question : A patient comes to the emergency department with an acute myocardial infarction. An electrocardiogram shows a heart rate of 116 beats/minute with frequent premature ventricular contractions. The patient experiences ventricular tachycardia and becomes unresponsive. 

After resuscitation, the patient moves to the intensive care unit. What is the priority nursing diagnosis for this patient?

A) Impaired physical mobility related to complete bed rest
B) Deficient knowledge related to emergency interventions
C) Social isolation related to restricted family visits
D) Anxiety related to the threat of death

Correct Answer is : D 

Question : The nurse is caring for a patient who has recently been admitted with a myocardial infarction. Based on clinical manifestations and nursing assessment, the patient has a nursing diagnosis of ineffective cardiac tissue perfusion related to decreased coronary
blood flow from coronary thrombus and atherosclerotic plaque. 

In order to promote adequate tissue perfusion, the nurse is aware that in the initial phase of treatment a nursing intervention that is particularly helpful in reducing myocardial oxygen
consumption is:
 

A) Relieving anxiety
B) Bed or chair rest
C) Frequent assessment of peripheral pulses
D) Scrupulous attention to fluid volume status

Ans: B

Question : The nurse provides care for a patient who experienced an extensive myocardial
infarction (MI). The patient exhibits behavior characteristic of the denial stage of the
grieving process. 

How should the nurse approach the patient's denial?
 

A) Reinforce and support the patient's denial.
B) Let the patient know that the nurse is available to talk.
C) Point out other patients with MIs who are doing well.
D) Explain to the patient that he needs to accept his diagnosis.
Ans: B