A patient who presented to the emergency room with a myocardial infarction (MI) becomes pale, diaphoretic, and hypotensive. What action should the nurse take first?
a. Notify the physician immediately.
b. Ensure that the patient has patent IV access.
c. Request assistance from respiratory ther-apy.
d. Inform the patient's family of the change in status.
A
If the left ventricle is badly damaged, cardiogenic shock may occur. Signs and symptoms are those that accompany decreased cardiac output, such as decreased BP, confusion, restlessness, diaphoresis, rapid and thready pulse, increased respiratory rate, cold and clammy skin, and dimi-nishing urinary output to less than 20 mL/hr. This condition is a medical emergency that requires immediate notification of the physician. The nurse should then ensure that the IV is patent. Res-piratory therapy assistance will likely be beneficial, especially if the patient's condition further deteriorates. The nurse should finally notify the patient's family about the change in status.
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