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. Partial thromboplastin time (PTT) 55 seconds: This PTT value is within the therapeutic range for a client on heparin therapy.
B. Hematocrit 45%: This hematocrit value is within normal limits and is not concerning.
C. White blood cell count 8,000/mm³: A WBC count of 8,000/mm³ is within the normal range and does not require reporting.
D. Platelets 74,000/mm³: A low platelet count (thrombocytopenia) can indicate heparin-induced thrombocytopenia (HIT), a potentially serious complication of heparin therapy.
Correct Answer is A
Explanation
A. The ST segment is above the isoelectric line. An elevated ST segment is a hallmark sign of acute myocardial infarction (MI), indicating myocardial injury.
B. The QRS intervals are 0.08 second. A QRS interval of 0.08 seconds is within the normal range and does not indicate myocardial infarction.
C. The QT interval is equal to the R to R interval. QT interval measurements are not diagnostic for acute MI.
D. The PR intervals are 0.15 second. A PR interval of 0.15 seconds is within the normal range and is not indicative of acute MI.