The nurse administers IV nitroglycerin to a client diagnosed with an acute myocardial infarction. In evaluating the effectiveness of this intervention, the nurse should monitor for:

A. A systolic murmur: A systolic murmur is often associated with valvular heart disease, particularly mitral regurgitation, which can sometimes result from papillary muscle dysfunction after a myocardial infarction. However, a systolic murmur is not a typical or immediate complication following an anterior-lateral wall MI. The focus in the early hours after an MI should be on more acute complications, such as dysrhythmias and hemodynamic stability, rather than a murmur, which may develop more gradually over time.

B. Ventricular dysrhythmias: Ventricular dysrhythmias are one of the most common and life-threatening complications in the immediate hours following an acute myocardial infarction (MI), especially with an anterior-lateral wall MI. These dysrhythmias occur due to the electrical disturbances caused by myocardial injury and ischemia. The heart muscle becomes more susceptible to abnormal electrical activity after the infarction, and monitoring for ventricular tachycardia or fibrillation is crucial. These arrhythmias can lead to sudden cardiac arrest, which is why they are a high priority for monitoring in the immediate post-MI period.

C. A pericardial friction rub: A pericardial friction rub is a sign of pericarditis, which can occur after an MI, particularly several days to a week later, rather than in the immediate post-MI period. While pericarditis is a possible complication of MI, it is less likely to present immediately after the infarction, especially in the first few hours. The nurse should monitor for pericarditis, but it is not as high a priority as dysrhythmias during the first hours after MI.

D. Renal insufficiency: While renal insufficiency can develop as a result of poor perfusion or shock following a myocardial infarction, it is not one of the most immediate or common complications to watch for in the first hours after an anterior-lateral MI. The primary concern in this acute phase is monitoring for cardiovascular complications, such as dysrhythmias, rather than renal function. Renal insufficiency would be a secondary concern, particularly if the patient is hypotensive or experiencing other signs of multi-organ involvement.

A. Call for the rapid response team and request a portable chest x-ray: While it is important to call for help and obtain imaging if needed, the immediate action is to address the potential pneumothorax by sealing the wound. The rapid response team and chest x-ray are necessary for further assessment, but securing the wound is the priority in the moment.

B. Turn the suction drainage system off and auscultate breath sounds: Turning off the suction drainage system and auscultating breath sounds may be part of subsequent assessment and care, but these actions are secondary to stopping the entry of air into the pleural space. Auscultating breath sounds would be important after the chest tube is secured to assess for signs of pneumothorax or other complications, but it is not the first priority.

C. Apply a sterile dressing and tape on three sides: The first priority when a chest tube becomes accidentally dislodged is to seal the wound to prevent air from entering the pleural space, which could cause a pneumothorax (collapsed lung). The correct method to seal the chest tube insertion site is to apply a sterile dressing and tape it on three sides. This technique allows air to escape from the pleural space but prevents air from entering, creating a temporary "one-way valve" effect. This is crucial in stabilizing the patient until further medical intervention can be provided. The fourth side of the dressing is left open to allow for air to escape, which helps prevent a tension pneumothorax

D. Notify the healthcare provider immediately: While notifying the healthcare provider is important, securing the wound to prevent further air entry is the immediate priority. Notifying the provider can occur after the dressing is applied. Prompt action to stabilize the chest tube site is crucial to prevent further respiratory distress or complications.