A nurse is providing care to a patient on fibrinolytic therapy. ...

[09madisonrousseau09]

A nurse is providing care to a patient on fibrinolytic therapy. Which of the following statements from the patient warrants further assessment and intervention by the critical care nurse?
 
  a. My back is killing me
  b. There is blood on my toothbrush
  c. Look at the bruises on my arms
  d. My arm is bleeding where my IV is

Question 2

A patient was admitted on the night shift with a diagnosis of acute myocardial infarction
 
  Upon auscultation, the nurse hears a harsh, holosystolic murmur along the left sternal border. The nurse notifies the physician immediately because the symptoms are indicate the patient has developed
 
  a. papillary muscle rupture.
  b. tricuspid stenosis.
  c. ventricular septal rupture.
  d. pericardial friction rub.

[diana chang]

Answer to Question 1

A
The nurse must continually monitor for clinical manifestations of bleeding. Mild gingival bleeding and oozing around venipuncture sites are common and not causes for concern. However, severe lower back pain and ecchymoses are suggestive of retroperitoneal bleeding. If serious bleeding occurs, all fibrinolytic heparin therapies are discontinued, and volume expanders, coagulation factors, or both are administered.

Answer to Question 2

C
Ventricular septal rupture is a new opening in the septum between the two ventricles. It creates a harsh, holosystolic murmur that is loudest (by auscultation) along the left sternal border. Papillary muscle rupture is auscultation of a new, high-pitched, holosystolic, blowing murmur at the cardiac apex. Tricuspid stenosis is a quiet murmur that becomes louder with inspiration and is located in the epigastrium area. A pericardial friction rub is a sound that can occur within 2 to 7 days after a myocardial infarction. The friction rub results from pericardial inflammation (pericarditis). Classically, a pericardial friction rub is a grating or scratching sound that is both systolic and diastolic, corresponding to cardiac motion within the pericardial sac.

[09madisonrousseau09]

Thank you

[diana chang]

Happy to help you