a client who had a myocardial infarction mi two days ago reports chest pain radiating to the left arm the nurse should take which immediate action
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Nursing Elites

ATI LPN

LPN Pharmacology Assessment A

1. A client who had a myocardial infarction (MI) two days ago reports chest pain radiating to the left arm. What should the nurse do immediately?

Correct answer: B

Rationale: Obtaining an ECG is crucial in this situation because it helps in assessing for potential complications, such as a recurrent MI or ongoing ischemia. This diagnostic test provides valuable information to guide further interventions and treatment. Administering morphine, oxygen, or nitroglycerin may be necessary but obtaining an ECG takes precedence to evaluate the cardiac status and determine the appropriate course of action. Administering morphine without assessing the current cardiac status through an ECG can mask important diagnostic clues. Applying oxygen and administering nitroglycerin are supportive measures that can follow the ECG to address potential hypoxia and ischemic pain relief, respectively.

2. A client with a diagnosis of myocardial infarction has a new activity prescription allowing the client to have bathroom privileges. As the client stands and begins to walk, the client begins to complain of chest pain. The nurse should take which action?

Correct answer: A

Rationale: In a client with myocardial infarction experiencing chest pain during activity, the priority action is to stop the activity immediately to reduce the heart's workload and oxygen demand. Assisting the client back to bed helps in reducing stress on the heart and can prevent worsening of the condition. Reporting the chest pain episode to the healthcare provider is important but should not delay taking immediate action to alleviate symptoms. Taking the client's blood pressure and administering nitroglycerin are secondary actions after ensuring the client's safety and comfort. Therefore, the correct action is to assist the client back into bed.

3. The client is receiving furosemide (Lasix) for heart failure. What potential side effect should the nurse monitor for?

Correct answer: A

Rationale: The correct answer is A: Hypokalemia. Furosemide, a loop diuretic, causes potassium loss, leading to hypokalemia. Monitoring potassium levels is crucial because hypokalemia can result in cardiac arrhythmias and muscle weakness. Choices B, C, and D are incorrect because furosemide does not typically cause hyperkalemia, hypernatremia, or hypoglycemia.

4. The client is reinforcing instructions for a low-sodium diet. Which statement by the client indicates a need for further teaching?

Correct answer: C

Rationale: The correct answer is C. Processed foods often contain high amounts of sodium, so they should be limited or avoided on a low-sodium diet. Choosing processed foods can lead to increased sodium intake, counteracting the purpose of following a low-sodium diet. Option A shows an understanding of avoiding added salt, Option B suggests using alternatives to regular salt, and Option D indicates a willingness to check food labels for sodium content, all of which are appropriate for a low-sodium diet. Therefore, the client's statement about eating processed foods freely is incorrect and requires further teaching.

5. A client with atrial fibrillation is receiving warfarin (Coumadin). The nurse should reinforce which instruction?

Correct answer: A

Rationale: The correct answer is A: Avoid foods high in vitamin K. Clients taking warfarin need to be cautious with their vitamin K intake because vitamin K can counteract the effects of the medication. Therefore, it is essential to avoid foods high in vitamin K to maintain the therapeutic effects of warfarin. Choice B is incorrect because increasing dairy product intake is not specifically related to warfarin therapy. Choice C is incorrect as high-fiber foods do not interfere with warfarin therapy. Choice D is incorrect as protein-rich foods are not contraindicated with warfarin therapy.

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