The nurse is caring for a client who had a myocardial infarction. The client develops increased pulmonary congestion; an increase in heart rate from 80 to 102 beats/min; and cold, clammy skin
Which action does the nurse implement before notifying the health care provider? a. Administer oxygen.
b. Increase the IV flow rate.
c. Place the client in supine position.
d. Prepare the client for surgery.
A
The nurse recognizes these manifestations as impending cardiogenic shock. Oxygen is needed to prevent further deterioration. The provider is notified immediately so that efforts can be made to reverse this condition because it has a mortality rate of 65% to 100%. IV fluids would enhance the respiratory edema. The client should be placed in high Fowler's position to assist with respi-rations. The client does not need surgery.
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