Author Question: During the administration of the thrombolytic agent to a patient with an acute myocardial infarction ... (Read 91 times)

ahriuashd · **on:** Jun 25, 2018

During the administration of the thrombolytic agent to a patient with an acute myocardial infarction (AMI), the nurse should stop the drug infusion if the patient experiences

a. bleeding from the gums.
b. increase in blood pressure.
c. a decrease in level of consciousness.
d. a nonsustained episode of ventricular tachycardia.

Question 2

Following an acute myocardial infarction (AMI), a patient ambulates in the hospital hallway. When the nurse is evaluating the patient's response to the activity, which assessment data would indicate that the exercise level should be decreased?

a. Blood pressure (BP) changes from 118/60 to 126/68 mm Hg.
b. Oxygen saturation drops from 99 to 95.
c. Heart rate increases from 66 to 92 beats/minute.
d. Respiratory rate goes from 14 to 20 breaths/minute.

yotaSR5 · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

ANS: C
The change in level of consciousness indicates that the patient may be experiencing intracranial bleeding, a possible complication of thrombolytic therapy. Some bleeding of the gums is an expected side effect of the therapy but not an indication to stop infusion of the thrombolytic medication. A decrease in blood pressure could indicate internal bleeding. A nonsustained episode of ventricular tachycardia is a common reperfusion dysrhythmia and may indicate that the therapy is effective.

Answer to Question 2

ANS: C
A change in heart rate of more than 20 beats over the resting heart rate indicates that the patient should stop and rest. The increases in BP and respiratory rate, and the slight decrease in oxygen saturation, are normal responses to exercise.