The nurse is caring for clients on a busy cardiac unit. Following morning assessment, the nurse would notify the physician with which of the following symptoms?
A) Dyspnea when ambulating from the bathroom
B) A noted irregular pulse rate prior to Lanoxin (digoxin) administration
C) Cyanosis with a pulse oximetry level of 92%
D) Pulsus paradoxus on vital sign assessment
D
Feedback:
Pulsus paradoxus is a difference of 10 mm Hg or more between the first Korotkoff sound noting systolic blood pressure heard during expiration and the first that is heard during inspiration. Pulsus paradoxus can signal a deteriorating condition including diminished stroke volume, compromised cardiac output, and death. This would be of high priority to notify the physician.
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