A nurse assesses a client with tachycardia. Which clinical manifestation requires immediate intervention by the nurse?
a. Mid-sternal chest pain
b. Increased urine output
c. Mild orthostatic hypotension
d. P wave touching the T wave
ANS: A
Chest pain, possibly angina, indicates that tachycardia may be increasing the client's myocardial workload and oxygen demand to such an extent that normal oxygen delivery cannot keep pace. This results in myocardial hypoxia and pain. Increased urinary output and mild orthostatic hypotension are not life-threatening conditions and therefore do not require immediate intervention. The P wave touching the T wave indicates significant tachycardia and should be assessed to determine the underlying rhythm and cause; this is an important assessment but is not as critical as chest pain, which indicates cardiac cell death.
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