The nurse is reviewing the client's medical record.

Exhibits

A nurse is reviewing the client's diagnostic results and vital signs. Which of the following actions should the nurse take? Select all that apply.

Rationale:

• Pain level: The client reports chest pain rated 7/10, which is significant and persistent. Promptly addressing pain is crucial for patient comfort and to reduce myocardial oxygen demand, which can limit the extent of myocardial damage. Pain relief is a primary immediate intervention in suspected cardiac events.
• ECG results: The ECG shows ST segment elevation and T wave changes, which are hallmark signs of acute myocardial infarction (STEMI). This is a life-threatening emergency requiring immediate intervention, such as oxygen, antiplatelets, or reperfusion therapy.

Rationale for Incorrect Options:

• Pedal pulses: Diminished pedal pulses, which, while not robust, are present and capillary refill is less than 2 seconds, indicating adequate peripheral perfusion are not the priority over signs of an evolving MI.
• Diaphoresis: Diaphoresis is a supporting symptom of myocardial infarction but is not as urgent as confirming ECG findings.
• Nausea: Nausea is a common but non-life-threatening symptom in cardiac events and should be managed after critical issues are addressed.
• Cholesterol level: Although elevated and a long-term risk factor, it is not immediately relevant in the context of an acute event.

A. +1 pedal pulses: A +1 pedal pulse indicates weak peripheral pulses, which may suggest poor circulation or peripheral artery disease but is not a direct sign of fluid volume overload.
B. Temperature of 38° C (100.4° F): A mild fever can indicate infection or inflammation but does not specifically indicate fluid volume overload. It requires further assessment for causes such as catheter-related infection during TPN therapy.
C. Urinary output of 20 mL in the past hour: Low urinary output (oliguria) may suggest dehydration, kidney impairment, or fluid retention but is not by itself a definitive sign of fluid overload. It may indicate inadequate kidney perfusion or acute kidney injury.
D. S3 heart sound: An S3 gallop is associated with increased fluid volume and can indicate fluid overload or heart failure. It results from rapid ventricular filling during diastole due to volume expansion, making it a key clinical finding in fluid volume overload.