A client who had a percutaneous coronary intervention (PCI) two weeks ago returns to the clinic for a follow up visit. The client has a postoperative ejection fraction of 30%. Today the client has lungs which are clear, +1 pedal edema, and a 5 pound weight gain. Which intervention should the nurse implement?

Click to highlight the findings that require follow up.

Neurological: Alert and oriented person, place, time, and situation Agitated. Denies headaches.

Cardiovascular: Reported chest pain described as pressure and tightness that is unrelieved with rest. Rapid regular rhythm. Normal heart tones. Radial and pedal pulses 2+. Capillary refill 2 seconds.

Respiratory: Rapid and shallow breaths. Clear breath sounds throughout bilateral lungs.

Gastrointestinal: Within normal limits (WNL).

Genitourinary: WNL.

Musculoskeletal M/MIL

Pain: Reported 7 on a 0 to 10 scale, tightness and pressure in chest. Started approximately 2 hours ago and got progressively worse, unrelieved by rest.

A client collapses while ambulating in the hallway. The nurse calls for help after verifying that the client is not breathing and has no palpable pulse. Which intervention should the nurse implement?

While assessing a client with type 2 diabetes mellitus (DM), the nurse observes an absence of hair growth on the client's lower legs. Which assessment provides further data to support this finding?

A client with a history of anxiety and asthma had an open cholecystectomy 3 days ago. Shortly after ambulating to the bathroom, the client is restless and troubled by shortness of breath. Which action should the nurse implement first?

The nurse is assessing a client who has returned from surgery following a thoracotomy. Which finding indicates the client is experiencing adequate gas exchange?

Which 2 statements from the client should the nurse recognize as a need for further education?

An older adult male client is admitted after three reported syncopal episodes at home. He has several bruises at various stages of healing noted over his arms and legs. The cardiac monitor shows atrial fibrillation (A-fib) with a ventricular response of 140 beats/minute. In addition to contacting the client's healthcare provider (HCP), which intervention should the nurse implement?

A client with stable angina secondary to ischemic heart disease receives a prescription for sublingual nitroglycerin prior to discharge from the hospital. During discharge teaching, the client assures the nurse a plan to fill the prescription via online mail order service as soon as arriving at home. How should the nurse respond?

A client recovering from cardiac surgery experiences a dysrhythmia, noted on the telemetry monitor. Which assessment finding is most likely to have contributed to the development of the dysrhythmia?

Reference Range:

• Total Calcium [8.4 to 10.6 mg/dL (2.10 to 2.50 mmol/L)]
• Sodium [136 to 145 mEq/L (136 to 145 mmol/L)]
• Potassium (K+) [3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)]

A client was admitted to the cardiac observation unit 2 hours ago reporting chest pain. On admission, the client's electrocardiogram (ECG) displays sinus bradycardia (SB) with ST segment depression, but no ventricular ectopy. The client suddenly reports a sharp increase in pain, telling the nurse, "I feel like an elephant just stepped on my chest." The ECG now displays Q waves and ST segment elevations in the anterior leads. Which interventions should the nurse perform?