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Difficulty: MediumPhysiological Adaptation

While evaluating a client recovering from a large anterior myocardial infarction in the intensive care unit, the nurse observes new-onset bilateral crackles extending to the mid-lung fields, severe jugular venous distension, and an audible S3 gallop. The client is restless, and their extremities are cool and mottled. Current vital signs include a blood pressure of 82/52 mm Hg, a heart rate of 124 beats/min, and a respiratory rate of 28 breaths/min. Based on these findings, which of the following prescribed interventions is the priority for the nurse to implement?

  1. Initiate a continuous intravenous infusion of dobutamine.Answer
  2. B
    Administer a rapid 500 mL bolus of 0.9% sodium chloride.
  3. C
    Position the client supine with the lower extremities elevated.
  4. D
    Administer an intravenous push dose of metoprolol.

Answer

Initiate a continuous intravenous infusion of dobutamine.
The client is exhibiting classic signs of cardiogenic shock (severe hypotension, compensatory tachycardia, cool and mottled extremities) accompanied by acute left and right-sided heart failure (pulmonary crackles, S3 gallop, jugular venous distension). Dobutamine is a positive inotropic agent that increases myocardial contractility and cardiac output, improving tissue perfusion without adding dangerous fluid volume to an already overloaded cardiovascular system.

Step-by-Step Solution

1
Analyze the client's physical assessment findings and vital signs.
The client presents with severe hypotension (82/52 mm Hg), tachycardia (124 beats/min), crackles, an S3 gallop, and jugular venous distension.
To identify the acute physiological complication occurring secondary to the myocardial infarction.
2
Synthesize the clinical data to determine the specific type of shock state.
The combination of poor peripheral perfusion (cool, mottled extremities) and severe fluid overload (pulmonary edema, JVD) indicates the client has developed cardiogenic shock.
Different types of shock require entirely distinct priority interventions, and misdiagnosing the shock state can lead to fatal outcomes.
3
Evaluate the prescribed interventions against the diagnosis of cardiogenic shock.
Dobutamine increases contractility; fluid boluses and leg elevation worsen fluid overload; metoprolol decreases contractility.
To select the action that safely improves cardiac output and tissue perfusion without exacerbating the existing pulmonary congestion.

Key Concept

Cardiogenic Shock Recognition and Management
Estimated Time:1m 15s
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Topics

Physiological Adaptation

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