When admitting a client who had an anterior wall ST-elevation myocardial infarction to the cardiac stepdown unit, which intervention should the nurse perform first?

Question

Quizplus · Accepted Answer

Dysrhythmias are the most frequent complication following myocardial infarction (MI). Ventricular fibrillation is the most common of these dysrhythmias and is regularly the cause of sudden cardiac death in clients with MI. The nurse should attach the cardiac monitor to the client before performing any other interventions. If ventricular tachycardia or premature ventricular contractions (PVCs) are observed, the client should be treated quickly (with antidysrhythmic drugs) as these rhythms usually precede ventricular fibrillation; early identification and treatment are imperative to improve outcomes. ST segment should also be monitored as reinfarction may occur; the client may or may not have the usual MI-related symptoms (eg, chest pain, shortness of breath, vomiting). (Option A) Jugular venous distension may indicate development of heart failure following MI; this is an important assessment but should be performed after the cardiac monitor is attached to the client. (Options C and D) Assessment of vital signs and auscultation of the heart and lungs are also important but should be performed after the cardiac monitor is attached to the client. Educational objective: Dysrhythmias are the most common complication following myocardial infarction. The nurse should immediately attach the cardiac monitor when the client is admitted before taking vital signs and performing other assessments.

When Admitting a Client Who Had an Anterior Wall ST-Elevation