Question

A nurse is performing a cardiac assessment for a client who had a myocardial infarction 2 days ago. Which of the following actions should the nurse take first after hearing the following sound?

a-obtain a 12-lead ECG for the client
b-request to obtain the client's cardiac enzymes
c-check the client's blood pressure manually
d-listen with the client on their left side

Answer 1

The nurse should check the client's blood pressure manually first.

Step-by-step explanation:

The nurse should check the client's blood pressure manually first after hearing the sound. This is because a myocardial infarction, or heart attack, can cause changes in blood pressure. By checking the blood pressure manually, the nurse can assess if the client's blood pressure is within normal range or if further intervention is needed. It seems like you mentioned hearing a sound, but the options provided don't include information about the sound or the assessment findings. If you could provide more details or context about the sound or the specific findings during the cardiac assessment, I would be better able to assist you in selecting the most appropriate action.