the nurse is caring for a client with a diagnosis of myocardial infarction mi which intervention is a priority during the acute phase
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Nursing Elites

HESI LPN

Adult Health Exam 1 Chamberlain

1. The nurse is caring for a client with a diagnosis of myocardial infarction (MI). Which intervention is a priority during the acute phase?

Correct answer: A

Rationale: Administering morphine is a priority intervention during the acute phase of myocardial infarction (MI). Morphine not only provides pain relief but also reduces myocardial oxygen demand, which is crucial in this situation. Choice B is incorrect because isometric exercises can increase myocardial oxygen demand and are not recommended during the acute phase of MI. Choice C is incorrect as elevating the head of the bed, not keeping the client flat, is preferred to reduce workload on the heart. Choice D is incorrect because fluid intake should be encouraged unless contraindicated, as adequate hydration is essential for cardiac function.

2. What intervention should the nurse implement for a client experiencing an anxiety attack?

Correct answer: C

Rationale: Administering prescribed anxiolytic medication is the most appropriate intervention for a client experiencing an anxiety attack. Anxiolytic medications can provide rapid relief from severe anxiety symptoms. Teaching deep breathing exercises (choice A) can be helpful for managing mild anxiety but may not be sufficient during an acute anxiety attack. Providing a quiet environment (choice B) is beneficial to reduce stimuli, but it may not address the immediate distress of an ongoing anxiety attack. Engaging the client in conversation (choice D) is generally not recommended during an anxiety attack as it can potentially exacerbate the symptoms by increasing stimulation.

3. A client with a chronic illness expresses frustration over their condition. What is the nurse's best response to support the client?

Correct answer: D

Rationale: The best response for the nurse to support a client expressing frustration over their chronic illness is to validate their feelings and listen to their concerns (Option D). This approach helps acknowledge the client's emotions, demonstrates empathy, and establishes a therapeutic relationship. By validating the client's feelings and actively listening to their concerns, the nurse offers a supportive environment for the client to express their frustrations. Choices A, B, and C are not the best responses in this situation. While joining a support group, discussing a cure, or focusing on positive aspects can be beneficial interventions, the immediate priority is to validate the client's feelings and provide a space for them to express their frustrations.

4. A client with diabetes exhibits a blood sugar of 350 mg/dL. What is the nurse's best action?

Correct answer: A

Rationale: In a client with diabetes presenting with a blood sugar level of 350 mg/dL, the best action for the nurse is to administer insulin as prescribed. High blood sugar levels can lead to complications like diabetic ketoacidosis, making prompt insulin administration crucial to lower the blood glucose level. Providing a carbohydrate-controlled snack would be inappropriate as it may further elevate blood sugar levels. Encouraging physical activity is not advisable when the blood sugar is significantly high, as exercise can raise blood sugar levels. Rechecking the blood sugar is necessary after administering insulin to monitor the response to treatment.

5. The nurse is caring for a client who is 4 hours post-operative from abdominal surgery. The client is complaining of severe pain. What is the nurse's first action?

Correct answer: A

Rationale: The correct first action for the nurse to take when a post-operative client complains of severe pain is to reassess the pain and its characteristics. Reassessment is crucial to understand the nature and intensity of the pain, which will guide the nurse in providing appropriate interventions. Administering pain medication may be necessary but should only be done after reassessment to ensure the right medication and dose are given. Notifying the surgeon may be required in certain situations, but reassessment of pain should precede this action. Encouraging relaxation techniques is not the priority when a client is experiencing severe pain post-operatively.

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