A client had an inferior wall myocardial infarction (MI). The nurse notes the client's cardiac rhythm as shown below. What action by the nurse is most important?

Correct Answer: A

Rationale: The correct action is to assess the client's blood pressure and level of consciousness. This is crucial in a client with an inferior wall MI to monitor for potential complications like cardiogenic shock. Assessing these vital signs can provide immediate information on the client's hemodynamic stability. Calling the health care provider or Rapid Response Team may be necessary based on assessment findings. Obtaining a permit for a temporary pacemaker insertion and preparing to administer antidysrhythmic medication are not the most immediate priorities and may not address the client's current needs.

Correct Answer: A

Rationale: The correct answer is A: Age. Age is a non-modifiable risk factor for coronary artery disease, meaning it cannot be changed or controlled. Hypertension, obesity, and smoking are modifiable risk factors as they can be managed through lifestyle changes or medical interventions. By controlling blood pressure, maintaining a healthy weight, and quitting smoking, individuals can reduce their risk of developing coronary artery disease. Age, however, is a natural process that cannot be altered. Therefore, focusing on managing modifiable risk factors is crucial in preventing coronary artery disease.

Correct Answer: C

Rationale: The correct answer is C because the pain of a myocardial infarction (MI) typically lasts longer than 15 minutes, unlike stable angina which lasts for a shorter duration. MI pain is usually described as intense, crushing, and prolonged, whereas stable angina pain is often triggered by exertion and relieved by rest or medication like nitroglycerin. Choices A, B, and D are incorrect because shortness of breath, feelings of fear or anxiety, and lack of relief from nitroglycerin are not definitive differentiating factors between MI and stable angina.

Correct Answer: C

Rationale: The correct answer is C because teaching the client about factor V Leiden testing is important in this scenario. Factor V Leiden is a genetic mutation that increases the risk of blood clot formation, including pulmonary embolism. Since the client has no known risk factors for PE, testing for this specific genetic mutation can help identify an underlying cause. Encouraging walking (choice A) is generally beneficial but may not address the root cause. Referring for smoking cessation (choice B) is not relevant in this case. Explaining that sometimes no cause is found (choice D) is not proactive and may lead to missed opportunities for prevention.

Correct Answer: C

Rationale: Correct Answer: C Rationale: 1. A pulmonary embolism is a blockage in one of the pulmonary arteries, affecting blood flow to the lungs. 2. This blockage limits perfusion, the process of blood flow through the lungs for oxygenation. 3. Oxygen saturation may not improve significantly because the blood clot interferes with perfusion, not ventilation. 4. Options A and B focus on ventilation issues, which may not be the primary concern in this case. 5. Option D is extreme and not supported by the information given about the client's condition. Summary: Choice C is correct because a pulmonary embolism affects perfusion in the lungs, leading to decreased oxygen saturation. Choices A, B, and D are incorrect as they focus on other issues not directly related to the client's condition.