Question

A client is admitted to the hospital with reports of chest pain. The nurse is monitoring the client and notifies the physician when the client exhibits

a) A change in apical pulse rate from 102 to 88 beats/min
b) Adventitious breath sounds
c) Decreased frequency of premature ventricular contractions (PVCs) to 4 per minute
d) Troponin levels less than 0.35 ng/mL

Answer 1

The nurse should notify the physician when adventitious breath sounds are present, as they can indicate serious respiratory issues such as pneumonia. The correct answer is option b).

Step-by-step explanation:

The nurse should notify the physician when the client exhibits adventitious breath sounds, which are not normal and suggest alterations in respiratory function. These sounds can indicate the presence of conditions such as pneumonia, where lungs may fill with mucus, leading to crackles or other abnormal sounds.

Other options presented, such as a decrease in apical pulse rate from 102 to 88 beats/min and a decrease in the frequency of premature ventricular contractions (PVCs), are generally not concerning as they show improvement or stabilization of the client's condition.

Monitoring vital signs and symptoms in a patient with chest pain is crucial for the timely diagnosis and treatment of cardiac conditions, especially acute myocardial infarction (MI). Symptoms such as angina pectoris, dyspnea, palpitations, and diaphoresis should be closely observed.