Client for changes in vital signs and for dysrhythmias

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Reference no: EM133845177

Question

Nursing Diagnoses and Interventions

The nurse assesses the client for changes in vital signs and for dysrhythmias. Other assessment findings related to MI include:

Dyspnea
Pallor
Diaphoresis
Weakness
Fatigue
Nausea
Vomiting
Fever

The client is transferred to the critical care unit for treatment and monitoring. She is still receiving oxygen at 2 L/min and IV nitroglycerin infusion. Her vital signs are stable. Her oxygen saturation is 94%, her breath sounds are clear, and she denies any pain at the present time.

The client's nurse develops a plan of care based on the following nursing problems:

Pain related to an imbalance between myocardial oxygen supply and demand.

Alteration in tissue perfusion (cardiac) related to blood flow interruption.

Activity intolerance related to imbalance between oxygen supply and demand.

Anxiety related to pain and fear.

Which intervention is most important for the nurse to include in the client's plan of care?

A. Continuous cardiac monitoring of heart rate and rhythm.

B. Auscultate lungs for adventitious sounds such as crackles.

C. Titrate oxygen to keep oxygen saturation greater than 93%.

D. Obtain blood to evaluate scheduled serum cardiac markers.

Reference no: EM133845177

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