The nurse is to begin a nitroglycerin infusion for a client diagnosed with an anterior wall myocardial infarction. Which assessment finding should the nurse report to the provider immediately?

Serum potassium of 5.2 mEq/L (normal 3.5 mEq/L-5.3 mEq/L.)

T wave depression on electrocardiogram

Heart rate of 90 beats per minute

Blood pressure of 90/50

Answer and Explanation

The Correct Answer is D

A. Serum potassium of 5.2 mEq/L: A potassium level of 5.2 mEq/L is slightly elevated but is still within a potentially acceptable range (normal is 3.5-5.3 mEq/L). While elevated potassium can be a concern, particularly in the context of an MI or with certain medications (like potassium-sparing diuretics), this level is not critically high. The nurse should monitor the potassium levels, but this is not an urgent finding requiring immediate reporting unless it increases further or is accompanied by significant symptoms (such as arrhythmias).

B. T wave depression on electrocardiogram (ECG): T wave depression can be a sign of ischemia or injury, which is common in the setting of an acute myocardial infarction. However, T wave changes are expected in this context and do not indicate an immediate emergency. The nurse should continue to monitor the ECG for any progression or worsening of ischemic changes but should prioritize concerns such as hypotension or worsening clinical status over this finding.

C. Heart rate of 90 beats per minute: A heart rate of 90 beats per minute is within normal limits (60-100 beats per minute), especially in the early stages of an MI. Nitroglycerin may cause a reflex tachycardia as a compensatory response to the decreased blood pressure, but a heart rate of 90 bpm is not an alarming finding. The nurse should continue to monitor the heart rate, but it is not the most pressing concern compared to hypotension. 4o mini

D. Blood pressure of 90/50: A blood pressure of 90/50 mmHg is significantly low and could indicate that the client is experiencing hypotension, which is a known side effect of nitroglycerin infusion. Nitroglycerin causes vasodilation, which can reduce blood pressure, especially in clients who are already at risk due to an acute myocardial infarction (MI). Low blood pressure can compromise perfusion to vital organs, including the heart, brain, and kidneys, and may lead to shock if not corrected promptly. This finding should be reported immediately to the healthcare provider, as it may require adjustment of the nitroglycerin dosage or discontinuation of the infusion.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. "I will report any unusual movements or behaviors to my healthcare provider."
This statement is correct and indicates that the client understands the potential side effects of levodopa/carbidopa. The medication can cause dyskinesia (uncontrolled movements) and other behavioral changes, so the client should report these symptoms to their healthcare provider for possible adjustment of the treatment plan.

B. "I may experience nausea while taking this medication."
This is also correct. Nausea is a common side effect of levodopa/carbidopa, especially when starting the medication. Taking it with food may help reduce this side effect, but some clients may still experience nausea.

C. "I will take this medication with a high-protein meal."
This statement is incorrect. Levodopa is absorbed best on an empty stomach or with a low-protein meal. Protein can interfere with the absorption of levodopa because amino acids (found in proteins) compete with levodopa for absorption across the blood-brain barrier. Therefore, it's recommended that levodopa/carbidopa be taken either 30 minutes before or 1 hour after meals, especially those high in protein.

D. "I will avoid sudden changes in position to prevent dizziness or falls."
This statement is correct. Levodopa/carbidopa can cause orthostatic hypotension (a sudden drop in blood pressure when standing up), which increases the risk of dizziness and falls. The client should be advised to change positions slowly and use support when rising from a sitting or lying position to avoid injury.

A. Apply 4L of nasal oxygen, administer a cough suppressant, and place client on bedrest B. Increase fluid intake, administer antibiotic(s), and facilitate adequate coughing C. Decrease activity, increase bronchodilator use, and encourage pursed lip breathing D. Place in prone position, begin steroid therapy, and monitor glucose levels

Correct Answer is B

Explanation

A) Apply 4L of nasal oxygen, administer a cough suppressant, and place client on bedrest:
This approach is inappropriate for a client with bacterial pneumonia. While oxygen therapy may be necessary for some clients, administering a cough suppressant in this scenario is counterproductive. Pneumonia often leads to the accumulation of secretions, and suppressing the cough would prevent the client from clearing mucus from their airways, potentially worsening the condition. Bedrest is generally indicated, but it should not be the sole intervention.

B) Increase fluid intake, administer antibiotic(s), and facilitate adequate coughing:
This is the most appropriate plan of care. Increasing fluid intake helps to thin the mucus, making it easier to clear from the airways, which is crucial in pneumonia. Antibiotics are necessary to treat the bacterial infection causing pneumonia. Facilitating adequate coughing helps the client expel secretions, reducing the risk of airway obstruction and improving oxygenation. Coarse rhonchi indicate the presence of mucus or secretions, which should be cleared with effective coughing.

C) Decrease activity, increase bronchodilator use, and encourage pursed lip breathing:
Decreasing activity is generally appropriate for a client with pneumonia to reduce fatigue, but increasing bronchodilator use is not typically indicated unless there is underlying bronchospasm, such as in asthma or COPD. Pursed lip breathing can help improve ventilation, but it is more beneficial for clients with obstructive airway diseases, not primarily for those with bacterial pneumonia. Therefore, this option does not address the immediate needs of the client.

D) Place in prone position, begin steroid therapy, and monitor glucose levels:
While prone positioning is helpful in some conditions like acute respiratory distress syndrome (ARDS), it is not routinely used for bacterial pneumonia unless the client has severe hypoxemia and requires advanced respiratory support. Steroid therapy is generally not indicated for bacterial pneumonia unless there is a specific inflammatory component (such as a superimposed condition like asthma or COPD). Monitoring glucose levels may be important in clients on steroid therapy, but this is not a primary concern in the treatment of bacterial pneumonia.

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