Eliot James, a 51-year-old truck driver, was admitted in the Cardiac Care Unit for an anterior Myocardial Infarction. On the third of hospitalization, Mr. James becomes increasingly restless. Pulse rate has increased to 126 beats per minute. The first nursing action is to:
A)Do a partial physical assessment, which includes vital signs, pulmonary auscultation, and cognitive functions.
B)Ask if the client is upset, because depression is common on the third day of hospitalization.
C)Re-administer oxygen per nasal catheter (prongs or tongs) at 6 liters, because restlessness is an early sign of cerebral hypoxia.
D)Decrease the rate of intravenous infusion to prevent fluid volume overload.

Question

Quizplus · Accepted Answer

An early indication of cardiac decompression is tachycardia. Therefore, the client's vital signs, mentation, and pulmonary status should be assessed to rule out this complication of myocardial infarction. Other causes of tachycardia are hypovolemia, anxiety, and pain. Assessment of pain and emotional status can be determined during cognitive assessment. Choices B, C, and D are incorrect because actions such as encouraging verbalization of feelings, administering oxygen, and decreasing the rate of intravenous infusion will be determined by the nurse's assessment of vital signs.

Eliot James, a 51-Year-Old Truck Driver, Was Admitted in the Cardiac