The nurse is caring for a client with a history of coronary artery disease who reports waking up with a sudden onset of vise-like chest pressure.

The client reports that the pain decreases at rest but continues to feel a constant mid-chest pressure. What intervention should the nurse perform in the immediate management of the client?

What intervention should the nurse perform in the immediate management of the client?

Choice A rationale
Comparing muscle strength bilaterally is important in assessing overall physical health and detecting any potential neuromuscular disorders. However, in the context of a client with a history of heart failure and elevated potassium levels, this would not be the most critical intervention. High potassium levels can lead to hyperkalemia, which can cause serious heart rhythm disturbances.
Choice B rationale
Observing the color and amount of urine can provide valuable information about the client’s hydration status and kidney function. In the case of heart failure, monitoring urine output can help assess the effectiveness of diuretic therapy and the progression of the disease. However, it is not the most immediate concern given the client’s high potassium levels.
Choice C rationale

Determining the apical pulse rate and rhythm is the most important intervention in this scenario. A serum potassium level of 6.2 mEq/L is higher than the normal range (3.5-5.0 mEq/L) and can cause life-threatening heart rhythm abnormalities. Therefore, the nurse should prioritize assessing the client’s heart rhythm to detect any abnormalities caused by this electrolyte imbalance.
Choice D rationale
Assessing the strength of deep tendon reflexes can help identify changes in neuromuscular function and is often used in neurological assessments. However, it is not the most critical intervention in the context of elevated potassium levels and heart failure.

Choice A rationale
The most crucial intervention for a nurse to include in the care plan of a client with a deep vein thrombosis (DVT) in the left leg who is on a heparin protocol is to monitor for bleeding side effects related to heparin therapy. Heparin is an anticoagulant medication that prevents the formation of blood clots. While it is an effective treatment for DVT, it can also increase the risk of bleeding. Therefore, it is essential for the nurse to closely monitor the client for any signs of bleeding, such as unusual bruising, blood in urine or stool, or bleeding gums.
Choice B rationale
While promoting movement can help prevent a pulmonary embolism (a potential complication of DVT), it is not the most crucial intervention when a client is on a heparin protocol. Excessive movement can potentially dislodge the clot, leading to a pulmonary embolism. Therefore, while movement is important, it should be done under the guidance of a healthcare professional.
Choice C rationale
Checking blood pressure and heart rate at least every 4 hours is a standard nursing intervention for many clients, not just those with DVT. While it is important to monitor these vital signs, it is not the most crucial intervention for a client with DVT on a heparin protocol.
Choice D rationale

Measuring the circumference of each calf can help assess for leg edema, which can be a sign of DVT. However, this is not the most crucial intervention for a client on a heparin protocol. The priority is to monitor for bleeding side effects related to the heparin therapy.