A nurse is assisting with the care of a client in the emergency department and reports severe radiating chest pain and shortness of breath. The client appears restless, frightened, and slightly cyanotic. The provider prescribes oxygen by nasal cannula at 4 L/min stat, cardiac enzyme levels, IV fluids, and a 12-lead ECG. Which of the following actions should the nurse take first?
Obtain a blood sample.
Initiate oxygen therapy.
Attach the leads for a 12-lead ECG.
Insert the IV catheter.
The Correct Answer is B
A. Obtain a blood sample. Although obtaining a blood sample is essential for cardiac enzyme levels, it is not the highest priority. Addressing oxygenation takes precedence to relieve hypoxia.
B. Initiate oxygen therapy. Oxygen is the first priority to improve oxygenation in a client showing signs of hypoxia (cyanosis, dyspnea), which can prevent further ischemic damage to the heart.
C. Attach the leads for a 12-lead ECG. While obtaining an ECG is essential for diagnosing myocardial ischemia, ensuring oxygenation is more critical in this moment.
D. Insert the IV catheter. An IV line is necessary to administer fluids and medications, but oxygenation should be prioritized first to stabilize the client.
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Correct Answer is D
Explanation
A. Barrel chest. A barrel chest is commonly seen in chronic obstructive pulmonary disease (COPD) rather than mitral valve stenosis.
B. Bradycardia. Bradycardia is not typically associated with mitral valve stenosis, as symptoms often include rapid or irregular heartbeat.
C. Clubbing of the fingers. Clubbing is associated with chronic hypoxia, often due to pulmonary conditions, not specifically with mitral valve stenosis.
D. Heart murmur. Mitral valve stenosis causes turbulent blood flow through the narrowed valve, resulting in a characteristic murmur.
Correct Answer is D
Explanation
A. Creatinine phosphokinase (CPK): CPK levels peak within 24 hours after an MI and return to normal within 2-3 days.
B. Myoglobin: Myoglobin rises within hours but returns to normal within 24 hours after MI.
C. Creatinine kinase-MB (CK-MB): CK-MB peaks 12-24 hours post-MI and returns to baseline within 2-3 days.
D. Troponin T: Troponin T remains elevated for up to 10-14 days after an MI, providing long-term evidence of myocardial injury.