A client experienced a myocardial infarction (MI) 12 hours ago. It is most important for the nurse to monitor which aspect of this client's care?
1. Breath sounds
2. Cardiac rhythm
3. Cardiac enzymes
4. Serum glucose level
Correct Answer: 2
Rationale 1: Monitoring breath sounds is not the most important assessment.
Rationale 2: The client is at severe risk of developing a dysrhythmia and must be closely monitored for changes in cardiac rhythm.
Rationale 3: It has been established that this client has experienced an MI. Further monitoring of cardiac enzymes will occur, but this is not the most important assessment.
Rationale 4: Monitoring the serum glucose level is not the most important assessment.
Global Rationale: The client is at severe risk of developing a dysrhythmia and must be closely monitored for changes in cardiac rhythm. Monitoring breath sounds and serum glucose levels are not the most important assessments. It has been established that this client has experienced an MI. Further monitoring of cardiac enzymes will occur, but this is not the most important assessment.
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