Question

The client is 3 hours post-MI. Which data would warrant immediate intervention by the nurse?

a. Bilateral peripheral pulses 2+.
b. The pulse ox reading is 96%
c. The urine output is 240 mL in the last 4 hrs.
d. Cool, clammy, diaphoretic skin.

Answer 1

Cool, clammy, diaphoretic skin in a client 3 hours post-MI would warrant immediate intervention as it may indicate cardiogenic shock, a serious and potentially fatal complication.

Step-by-step explanation:

The client is 3 hours post-MI (myocardial infarction). Among the data present, the symptom that would warrant immediate intervention by the nurse is d. Cool, clammy, diaphoretic skin. This condition suggests that the client may be in cardiogenic shock, a potentially fatal complication of a heart attack where the heart is unable to supply enough blood to the organs of the body. Immediate medical intervention is critical to stabilize the client's condition. While bilateral peripheral pulses 2+, pulse oximetry reading of 96%, and urine output of 240 mL in the last 4 hours are within normal ranges post-MI, the presence of cool, clammy skin is concerning and needs prompt attention.