A nurse is caring for a patient with a confirmed myocardial infarction. The physician orders morphine for pain relief.
What is the primary action of morphine in the management of MI?

Choice A rationale

Assessing peripheral pulses distal to the insertion site is a critical nursing intervention following cardiac catheterization. The procedure involves arterial puncture, which carries a risk of arterial occlusion, thrombosis, or embolism. Regular pulse checks help ensure that blood flow to the extremity remains adequate. Comparing the pulse strength to the baseline and the unaffected limb allows for early detection of vascular compromise, which requires immediate intervention to prevent permanent tissue damage or limb ischemia.

Choice B rationale

The insertion site for a cardiac catheterization, usually the femoral or radial artery, must be monitored closely for bleeding or hematoma formation. Because the procedure involves a large-bore puncture in a high-pressure vessel, the risk of hemorrhage is significant, especially if the patient is on anticoagulants. A hematoma can also lead to local tissue compression or nerve injury. Frequent visual inspection and palpation of the site are necessary to ensure the effectiveness of the pressure dressing.

Choice C rationale

Evaluating the temperature and color of the affected extremity provides essential data regarding the neurovascular status. A cold, pale, or cyanotic limb suggests impaired arterial circulation or a possible clot at the puncture site. Monitoring these parameters alongside pulse checks provides a comprehensive assessment of perfusion. If the extremity becomes cool or mottled, it indicates a medical emergency such as an acute arterial occlusion, which is a known complication of invasive percutaneous cardiovascular procedures.

Choice D rationale

Early ambulation is usually contraindicated immediately following cardiac catheterization if a femoral approach was used. Patients are typically required to remain on bed rest with the affected extremity kept straight for several hours to prevent arterial bleeding and allow the puncture site to seal properly. Encouraging ambulation too soon increases the risk of hematoma formation or retroperitoneal hemorrhage. Therefore, the nurse must enforce strict activity restrictions according to the facility protocol rather than encouraging early movement.

Choice E rationale

Restricting fluid intake is generally contraindicated after cardiac catheterization unless the patient has a specific condition like severe heart failure. Patients receive radiopaque contrast dye during the procedure, which is nephrotoxic. Increasing fluid intake, either orally or intravenously, is encouraged to help flush the dye through the kidneys and prevent contrast-induced nephropathy. Adequate hydration ensures that the concentration of the dye in the renal tubules is minimized, thereby protecting the patient's renal function post-procedure.

Choice A rationale

For a client in acute heart failure following a myocardial infarction, the administration of 0.9 percent sodium chloride is often contraindicated or requires extreme caution. Acute heart failure involves the heart's inability to pump effectively, leading to pulmonary congestion and systemic fluid volume excess. Adding isotonic saline, which remains in the extracellular space, can worsen pulmonary edema and increase the workload on the failing left ventricle. The nurse should clarify this order to prevent further respiratory distress and cardiac strain.

Choice B rationale

Bumetanide is a potent loop diuretic used to rapidly reduce fluid volume in patients with acute heart failure and pulmonary congestion. A dose of 1 mg IV bolus every 12 hours is a standard intervention aimed at promoting diuresis and reducing preload. This helps clear fluid from the lungs and improves oxygenation. The nurse would monitor urine output and electrolyte levels, specifically looking for hypokalemia, as loop diuretics cause the kidneys to excrete potassium along with water and sodium.

Choice C rationale

Monitoring serum potassium is a critical and appropriate action for a patient with heart failure and a recent myocardial infarction. Potassium levels must stay within 3.5 to 5.0 mEq/L to maintain cardiac electrical stability. Many heart failure treatments, including diuretics and ACE inhibitors, significantly alter potassium levels. In the context of an injured myocardium following an infarct, any electrolyte imbalance can trigger lethal arrhythmias. Therefore, obtaining baseline and serial potassium levels is a standard of care that does not require clarification.

Choice D rationale

Morphine sulfate is frequently used in the treatment of acute heart failure and myocardial infarction. Beyond its analgesic properties for chest pain, morphine acts as a vasodilator, which reduces both preload and afterload. This effect decreases the myocardial oxygen demand and helps alleviate the anxiety associated with dyspnea. A dose of 2 mg IV bolus every 2 hours as needed is a common and appropriate prescription to manage symptoms and improve hemodynamics in the acute phase of cardiac distress.