Mr. 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:
Explanation
Answer - A - 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.
