A client had an inferior wall myocardial infarction (MI). The ...

[future617RT]

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?
  a.
  Assess the client's blood pressure and level of consciousness.
  b.
  Call the health care provider or the Rapid Response Team.
  c.
  Obtain a permit for an emergency temporary pacemaker insertion.
  d.
  Prepare to administer antidysrhythmic medication.

Question 2

A nurse is assessing a client who had a myocardial infarction. Upon auscultating heart sounds, the nurse hears the following sound. What action by the nurse is most appropriate? (Click the media button to hear the audio clip.)
 
  a. Assess for further chest pain.
  b. Call the Rapid Response Team.
  c. Have the client sit upright.
  d. Listen to the client's lung sounds.

[sarah_brady415]

Answer to Question 1

ANS: A
Clients with an inferior wall MI often have bradycardia and blocks that lead to decreased perfusion, as seen in this ECG strip showing sinus bradycardia. The nurse should first assess the client's hemodynamic status, including vital signs and level of consciousness. The client may or may not need the Rapid Response Team, a temporary pacemaker, or medication; there is no indication of this in the question.

Answer to Question 2

ANS: D
The sound the nurse hears is an S3 heart sound, an abnormal sound that may indicate heart failure. The nurse should next assess the client's lung sounds. Assessing for chest pain is not directly related. There is no indication that the Rapid Response Team is needed. Having the client sit up will not change the heart sound.

[future617RT]

Thank you

[sarah_brady415]

No problemo