A nurse is caring for a client who reports a new onset of severe chest pain. Which of the following actions should the nurse take to determine if the client is experiencing a myocardial infarction?

Choice A reason: Nausea and faintness Nausea and faintness can be symptoms of hypovolemic shock. Hypovolemic shock occurs when the body loses a significant amount of blood or fluids, leading to a decrease in blood pressure and inadequate oxygen supply to the organs. This can cause various symptoms, including nausea and faintness, as the body struggles to maintain normal function.

Choice B reason: Neurologic deficits and apprehension Neurologic deficits and apprehension can also be symptoms of hypovolemic shock. Neurologic deficits refer to abnormal neurologic function of a body area due to injury of the brain, spinal cord, muscles, or nerves. Apprehension, or anxiety, can occur as the body responds to the stress of significant blood or fluid loss.

Choice C reason: Hypertension and tachypnea Hypertension, or high blood pressure, is not typically a symptom of hypovolemic shock. In fact, hypovolemic shock is usually characterized by hypotension, or low blood pressure, due to the loss of blood or fluids. Tachypnea, or rapid breathing, can be a symptom of hypovolemic shock, but it would not typically be accompanied by hypertension in this context.

Choice D reason: Diaphoresis and oliguria Diaphoresis (excessive sweating) and oliguria (reduced urine production) can be symptoms of hypovolemic shock. Diaphoresis can occur as the body attempts to cool itself in response to the stress of significant blood or fluid loss. Oliguria can occur as the kidneys receive less blood flow due to the decrease in blood volume, leading to decreased urine production.

- Step 1: Identify the required dose in grams. The client is scheduled to receive 30 grams of lactulose.

- Step 2: Identify the concentration of the available solution. The available solution contains 5 grams of lactulose per 10 mL.

- Step 3: Calculate the volume of solution needed to deliver the required dose. We can set up a proportion to solve for this:

- 5 grams is to 10 mL as 30 grams is to X mL.

- In other words, 5 g : 10 mL = 30 g : X mL.

- Step 4: Solve for X using cross-multiplication and division:

- Cross-multiplication gives us: 5 g × X mL = 30 g × 10 mL.

- Simplifying this gives us: 5X = 300.

- Dividing both sides by 5 gives us: X = 300 ÷ 5.

- Calculating the division gives us: X = 60.

60 mL of the lactulose solution should be poured into the medication cup to administer the required dose of 30 grams.