The wife of a 64-year-old male client calls 911 to report that her husband was raking leaves in the yard, clutched his chest, and is having severe crushing chest pain (10/10 on a 0 to 10 pain intensity scale). The client is quickly attached to the cardiac monitor, which reveals ST elevation and a 12-lead ECG is transmitted to the emergency department (ED) for further evaluation. EMS obtains a rapid health assessment and determines that the client has no history of cardiac disease or hypertension and has no allergies. The ECG reveals that he currently has ST elevations. Vital signs: temperature = 99.2°F (37.3°C) apical heart rate = 88 beats/min and regular, respirations = 24 breaths/min, blood pressure (BP) = 178/98 mm Hg. Oxygen saturation is 89% (on room air [RA]). Oxygen at 3 L/min is applied to the client and an IV catheter is inserted. Aspirin 325 mg is administered with nitroglycerin 0.4 mg sublingually. The client arrives at the ED and the nurse assesses the client and notes the following: • Chest pain is a pressure-like feeling at 8/10 on a 0 to10 pain intensity scale • Temperature = 99.2°F (37.3°C) • Apical heart rate = 98 beats/min and irregular • Respirations = 24 breaths/min • Blood pressure (BP) = 154/84 mm Hg • Oxygen saturation = 93% (on 3 L/min oxygen via NC) IV morphine sulfate is administered as prescribed. The nurse maintains oxygen therapy at 3 L/min, obtains another 12-lead ECG, and places the client on a continuous cardiac monitor. Laboratory and diagnostic studies are prescribed including complete metabolic profile (CMP), cardiac troponin I and troponin T. Reperfusion (antithrombotic) therapy is initiated. An echocardiography imaging, and coronary angiography with possible percutaneous coronary intervention is prescribed. 1. which client assessment findings require immediate follow-up by the nurse at this time? 2. Based on the assessment data, the nurse recognizes that the client is at risk for which potential complications? 3. Based on the nurse’s assessment findings, the nurse determines that the client’s temperature reading ____________________ and the client’s BP reading ___________________________. The ST elevation noted on the initial ECG most likely _______________________. 4. Based on the cardiac rhythm strip, names the nursing interventions that the nurse need to prepare for the patient? 5. Why the nurse needs to monitor the client closely while awaiting transfer from the ED to the cardiac catheterization department?
[Expert Solution]: The wife of a 64-year-old male client…
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