Question

The nurse is assessing a client who has left ventricular failure secondary to a myocardial infarction. Which clinical manifestation of poor organ perfusion does the nurse monitor for in this client?

a. Headache
b. Hypertension
c. Urine output of less than 30 mL/hr
d. Heart rate of 55 to 60 beats/min

Answer 1

In a client with left ventricular failure secondary to myocardial infarction, the nurse should monitor for a urine output of less than 30 mL/hr, which can indicate poor renal perfusion and potential organ failure.

Step-by-step explanation:

The nurse monitoring a client with left ventricular failure secondary to a myocardial infarction should watch for clinical manifestations of poor organ perfusion. Among the options provided, a urine output of less than 30 mL/hr is indicative of renal hypoperfusion and is a concern in this scenario. This can be a sign of heart failure leading to kidney failure and is associated with Hypoperfusion due to the heart's decreased ability to pump blood effectively.

Headaches may not be directly related to poor perfusion, hypertension is often not immediately associated with heart failure, and a heart rate of 55 to 60 beats/min can be normal for some individuals, though it may indicate bradycardia in others. Therefore, the critical sign of poor perfusion to monitor in this case is reduced urine output, which is a more specific and urgent indicator of organ function being compromised.