The nurse is caring for a client who had a large anterior wall myocardial infarction (MI) 24 hours ago. Which finding is most important to report to the health care provider (HCP)?

Question

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A large anterior wall MI can affect the pumping ability of the left ventricle, putting the client at risk for developing heart failure and cardiogenic shock. The new development of pulmonary congestion on x-ray, auscultation of a new S₃heart sound, crackles on auscultation of breath sounds, or jugular venous distension can signal heart failure and should be reported immediately to the HCP. (Option A) Clients may experience nausea and vomiting during an MI resulting from stimulation of the vomiting center by severe pain or from vasovagal reflexes initiated from the area of the infarction. This finding is not as high a priority as the S₃heart sound. (Option C) Dysrhythmias are a common complication after an MI. Occasional PVCs are not significant, but the nurse should further assess the client's potassium level and assess the apical-radial pulse for the presence of a pulse deficit. (Option D) An increase in temperature following a MI is usually due to a systemic inflammatory process caused by myocardial cell death. The elevation may last as long as a week. This finding is not as significant as the S₃heart sound. Educational objective: The nurse should immediately report the new development of pulmonary congestion on x-ray, auscultation of a new S₃ heart sound, crackles on auscultation of breath sounds, or jugular venous distension in the post MI client to the HCP. These findings may indicate the development of heart failure or cardiogenic shock.

The Nurse Is Caring for a Client Who Had a Large