Difficulty: Medium
Average Score: 87%
Simulated
The nurse is caring for a client recovering from myocardial infarction who is presenting with a heart rate of 110 beats per minute, a blood pressure of 86/58 mmHg, crackles, shortness of breath, dusky skin, and jugular vein distention. Which action should the nurse recognize as the highest priority?
Correct answer
D
Rationale
These findings suggest cardiogenic shock with pulmonary edema. Fluid replacement may be needed, but cautiously, to optimize preload.