The nurse admits to the coronary care unit a patient diagnosed with an acute myocardial infarction. The patient's blood pressure reading is 86/38 secondary to an infusing nitroglycerine drip.
Pulse rate is 120 beats/min and respirations are 14 breaths/min. The patient is pale and grimacing, and moans occasionally. What nursing diagnoses would the nurse anticipate for this patient? Select all that apply.
a. Acute Pain
b. Anxiety related to shortness of breath
c. Risk for shock
d. Decreased Cardiac Output
e. Decreased Cardiac Perfusion
Question 2
The nurse plans to maintain hydration for the patient at risk for thrombus formation. What evaluation finding is an indicator that the intervention is successful?
a. The patient denies pain in the lower legs.
b. The patient denies chest pain or difficulty breathing
c. Urine output exceeds 1,500 mL per 24-hour period.
d. There is a weight gain of 5 pounds within 24 hours.
To check pupillary reflexes the nurse first holds the penlight
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