A patient with a history of a myocardial infarction has chest pain. The patient's skin color is grayish, blood pressure is 88/70 mm Hg, pulse is 116 beats/minute and irregular, and respirations are 30/minute. Which action should the nurse take?
a. Place the patient supine.
b. Infuse 0.9% normal saline wide open.
c. Notify the registered nurse.
d. Check the urine specific gravity.
ANS: C
C. The nurse needs the physician to be informed so orders can be received to aid the critically ill patient. A and B are contraindicated for this patient, who may have cardiogenic shock as increased fluid could overwhelm the heart. Sitting up reduces fluid return to the heart and eases breathing. D. Urine specific gravity is used to determine fluid volume status and is not needed for this patient.
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