Which client electrocardiography (ECG) change from baseline will alert the nurse to possible development of hypercalcemia?

Choice A reason: Increasing morphine without monitoring risks respiratory depression, especially in an unresponsive patient. Titrating with a respiratory rate limit is safer, making this incorrect, as it lacks safeguards compared to the nurse’s best intervention to manage pain and avoid complications.

Choice B reason: Increasing the morphine drip to relieve grimacing while monitoring for a respiratory rate below 10 breaths/min balances pain control and safety. This aligns with palliative care protocols, making it the correct intervention for the nurse to manage the patient’s discomfort effectively.

Choice C reason: Decreasing morphine and switching to Versed may not address pain and risks withdrawal. Titrating morphine is more appropriate, making this incorrect, as it’s less effective than the nurse’s focus on maintaining pain relief while monitoring respiratory status.

Choice D reason: Asking the family to leave doesn’t address the patient’s pain or ventilator resistance. Adjusting morphine is the priority, making this incorrect, as it’s irrelevant compared to the nurse’s intervention to manage the patient’s discomfort and sedation needs.

Choice A reason: Decreased cardiac output is a hallmark of cardiogenic shock, as the heart fails to pump adequately. This aligns with shock pathophysiology, making it a correct manifestation the nurse would expect when assessing a client for cardiogenic shock in a clinical setting.

Choice B reason: Increased pulse rate occurs in cardiogenic shock as the body compensates for low cardiac output. This aligns with cardiovascular assessment findings, making it a correct manifestation the nurse would identify in a client experiencing cardiogenic shock during evaluation.

Choice C reason: Postural hypotension is more typical of hypovolemic or orthostatic issues, not cardiogenic shock, which features weak pulses. Weak thready pulse is correct, making this incorrect, as it’s not a primary sign of cardiogenic shock in the nurse’s assessment.

Choice D reason: Bounding pulse suggests hyperdynamic circulation, not cardiogenic shock, where perfusion is poor. Weak thready pulse is typical, making this incorrect, as it does not reflect the compromised cardiac output expected in the nurse’s evaluation of cardiogenic shock.

Choice E reason: Weak thready pulse indicates poor perfusion in cardiogenic shock due to reduced cardiac output. This aligns with peripheral vascular assessment, making it a correct manifestation the nurse would expect when assessing a client in cardiogenic shock.

Choice F reason: Hypertension is not typical in cardiogenic shock, which often presents with hypotension due to pump failure. Pink frothy sputum is correct, making this incorrect, as it contradicts the hemodynamic profile in the nurse’s assessment of cardiogenic shock.

Choice G reason: Capillary refill greater than 3 seconds reflects poor perfusion in cardiogenic shock, consistent with low cardiac output. This aligns with peripheral assessment findings, making it a correct manifestation the nurse would note in a client with cardiogenic shock.

Choice H reason: Capillary refill less than 3 seconds suggests normal perfusion, not cardiogenic shock, where refill is delayed. Greater than 3 seconds is correct, making this incorrect, as it does not align with the poor perfusion in cardiogenic shock assessment.

Choice I reason: Pink frothy sputum indicates pulmonary edema, common in cardiogenic shock due to left heart failure. This aligns with respiratory assessment findings, making it a correct manifestation the nurse would expect in a client with cardiogenic shock.