A nurse is reviewing the cardiac monitor strip for a client who is recovering from an acute myocardial infarction. Which of the following findings should the nurse report to the provider immediately?

Sinus tachycardia rate 104/min

Two premature ventricular contractions per minute

First degree heart block

A new onset of atrial fibrillation

Answer and Explanation

The Correct Answer is D

A. Sinus tachycardia rate 104/min: Mild sinus tachycardia may occur in response to pain, anxiety, or hypovolemia and is usually not immediately life-threatening. While it should be monitored, it does not require urgent reporting unless it worsens or is accompanied by other concerning signs.

B. Two premature ventricular contractions per minute: Occasional PVCs can be benign, especially in a post-MI patient, and may not require immediate intervention. Frequent or paired PVCs, or those occurring in runs, are more concerning for ventricular arrhythmias.

C. First degree heart block: This is characterized by a prolonged PR interval but generally does not compromise cardiac output. It is often stable and can be monitored rather than reported as an urgent finding.

D. A new onset of atrial fibrillation: New-onset atrial fibrillation following a myocardial infarction increases the risk of decreased cardiac output, thromboembolism, and hemodynamic instability. This arrhythmia requires immediate notification of the provider for assessment and initiation of appropriate interventions such as rate or rhythm control and anticoagulation.

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Correct Answer is D

Explanation

A. Discoloration at the postoperative site: Mild bruising or ecchymosis around the incision is common after arthroscopy and generally expected. It does not usually indicate a complication requiring immediate reporting.

B. Urinary output 150 mL/hr: A urinary output of 150 mL/hr is above the minimum expected hourly output (typically 30 mL/hr) and suggests adequate renal perfusion. This finding does not require immediate notification.

C. Client report of pain at the incision site: Some pain at the incision site is expected postoperatively. While pain should be managed, reporting to the provider is not urgent unless it is uncontrolled or accompanied by other concerning signs.

D. Blood pressure 78/38 mm Hg: Hypotension at this level is significant and can indicate hypovolemia, bleeding, or shock. Immediate reporting to the provider is necessary to prevent organ hypoperfusion and initiate prompt interventions.

A. "Have several small meals during the day." B. "Limit snacking between meals." C. "Eat one food at a time during meals." D. "Consume a full-liquid diet."

Correct Answer is A

Explanation

A. "Have several small meals during the day.": Smaller, more frequent meals reduce the work of breathing required during eating, as large meals can increase diaphragmatic pressure and exacerbate dyspnea in clients with COPD. This strategy helps maintain adequate nutritional intake without causing fatigue or shortness of breath.

B. "Limit snacking between meals.": Restricting snacks may lead to insufficient caloric intake, which can worsen weight loss and muscle weakness common in COPD. Frequent small meals, including healthy snacks, are preferred to maintain energy levels and support respiratory muscle function.

C. "Eat one food at a time during meals.": While simplifying meals can help some clients, the key intervention for dyspnea management during meals is controlling meal size and frequency. Focusing on single foods does not significantly reduce the work of breathing.

D. "Consume a full-liquid diet.": A full-liquid diet is generally unnecessary unless swallowing difficulties exist. Liquids alone may not provide sufficient calories or protein for clients with increased energy expenditure due to COPD and may contribute to malnutrition.

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