A client had an acute myocardial infarction. What assessment ...

[jrubin]

A client had an acute myocardial infarction. What assessment finding indicates to the nurse that a significant complication has occurred?
 
  a. Blood pressure that is 20 mm Hg below baseline
  b. Oxygen saturation of 94 on room air
  c. Poor peripheral pulses and cool skin
  d. Urine output of 1.2 mL/kg/hr for 4 hours

Question 2

A client is on a dopamine infusion via a peripheral line. What action by the nurse takes priority for safety?
 
  a. Assess the IV site hourly.
  b. Monitor the pedal pulses.
  c. Monitor the client's vital signs.
  d. Obtain consent for a central line.

[pratush dev]

Answer to Question 1

ANS: C
Poor peripheral pulses and cool skin may be signs of impending cardiogenic shock and should be reported immediately. A blood pressure drop of 20 mm Hg is not worrisome. An oxygen saturation of 94 is just slightly below normal. A urine output of 1.2 mL/kg/hr for 4 hours is normal.

Answer to Question 2

ANS: A
Dopamine should be infused through a central line to prevent extravasation and necrosis of tissue. If it needs to be run peripherally, the nurse assesses the site hourly for problems. When the client is getting the central line, ensuring informed consent is on the chart is a priority. But at this point, the client has only a peripheral line, so caution must be taken to preserve the integrity of the client's integumentary system. Monitoring pedal pulses and vital signs give indications as to how well the drug is working.

[jrubin]

TYSM

[CAPTAINAMERICA]

Excellent