Difficulty: Medium
Average Score: 68%
Simulated
The nurse is caring for a client diagnosed with an anterior myocardial infarction 2 days ago. Upon assessment, the nurse identifies a new systolic murmur at the apex. The nurse should first:
Correct answer
A
Rationale
A new systolic murmur post-myocardial infarction may indicate complications like ventricular septal rupture or mitral regurgitation. Assessing vital signs first helps determine the client's stability and guides further actions.