A charge nurse on a cardiovascular step-down unit is evaluating the clinical status of multiple clients after receiving the morning shift report. Which of the following client findings indicate an acute deterioration that requires immediate intervention? Select all that apply.
- A client with heart failure who has developed a new, frequent, pink-tinged frothy cough and bilateral lung crackles.Answer
- A client with a permanent pacemaker inserted yesterday who exhibits pacing spikes without subsequent QRS complexes on the telemetry monitor.Answer
- CA client with atrial fibrillation receiving a continuous diltiazem infusion who has a resting heart rate of 88 beats/minute.
- DA client with a history of peripheral arterial disease who reports bilateral calf pain that occurs when walking to the bathroom and is relieved by rest.
- A client who is 4 hours post-cardiac catheterization via the right femoral artery and reports severe lower back pain and dizziness.Answer
Answer
The correct findings requiring immediate intervention are the client with heart failure developing a pink-tinged frothy cough, the client with pacemaker spikes without QRS complexes, and the post-cardiac catheterization client with severe back pain and dizziness.
The correct choices all represent unexpected, acute, and life-threatening complications. Acute pulmonary edema severely compromises breathing and oxygenation. A pacemaker failing to capture severely compromises cardiac output and circulation. Retroperitoneal bleeding is a hemorrhagic emergency that causes hypovolemic shock. All three require immediate nursing and medical intervention.
Step-by-Step Solution
Key Concept
Prioritization of Care: Acute vs. Chronic and Unexpected vs. Expected Findings