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A client has intra-arterial blood pressure monitoring after a myocardial infarction. The nurse notes the clients heart rate has increased from 88 to 110 beats/min, and the blood pressure dropped from 120/82 to 100/60 mm Hg. What action by the nurse is most appropriate?
- A. Allow the client to rest quality.
- B. Assess the client for bleeding.
- C. Document the findings in the chart.
- D. Medicate the client for pain.
Correct Answer: B
Rationale: A major complication related to intra-arterial blood pressure monitoring is hemorrhages from the insertion site. Since the vital signs are out of the normal range, are a chance, and are consistent with blood loss, the nurse should assess the client for any bleeding associated with the arterial line. The nurse should document the findings after a full assessment. The client may or may not need pain medication and rest, the nurse first needs to assess for bleeding.
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A nursing student studying acute coronary syndromes learns that the pain of a myocardial infarction (MI) differs from stable angina in which way? (Select all that apply.)
- A. Accompanied by shortness of breath
- B. Feelings of fear or anxiety
- C. Lasts longer than 15 minutes
- D. Not relieved by rest or nitroglycerin
- E. Triggered by exertion
Correct Answer: A,B,C,D
Rationale: The pain of a myocardial infarction is typically accompanied by shortness of breath, feelings of fear or anxiety, lasts longer than 15 minutes, and is not relieved by rest or nitroglycerin, unlike stable angina. Stable angina is often triggered by exertion, but MI pain can occur at rest.
A client received tissue plasminogen activator (t-PA) after a myocardial infarction and now is an an intravenous infusion. The nurse is a client to respond, and now the client needs this medication. What response is the nurse is best.
- A. The t-PA didid dissolve the entire coronary clot.
- B. The heparin keeps that artery from getting blocked gain.
- C. The heparin keeps that artery from getting blocked gain.
- D. The heparin prevents a stroke from occurring as the t-PA wears off.
Correct Answer: B
Rationale: After the original intracanoary clot has dissolved, large amounts of thrombin are released into the bloodstream, increasing the chance of the vessel reoulding. The other statements are not accurate. Heparin is not a blood thinner, although neurologist may refer is a not.
A nurse is teaching about a positive inotrope to a client and their spouse. Which statement by the nurse is most appropriate to explain the action of these drugs to the client and spouse?
- A. It constrsits vessels, improving blood flow.
- B. It dilates vessels, which leaves the work of the heart.
- C. It increases the force of the hearts contractions.
- D. It slows the heart rate down for better filling.
Correct Answer: C
Rationale: A positive inotrope is a medication that increases the strength of the hearts contractions. The other options are not correct.
A client is receiving an infusion of tissue plasminogen activator (t-PA). The nurse assesses the client to be determined to response, please, and time. What action by the nurse is best?
- A. Assess the clients papillary responses.
- B. Request an neurologic consultation.
- C. Stop the infusion and call the provider.
- D. Take and document a full set of vital signs.
Correct Answer: C
Rationale: A change in neurologic status in a client receiving t-PA could indicate intracranial hemorrhage. The nurse should stop the infusion and notify the provider immediately. A full assessment, including papillary responses and vital signs, occurs next. The nurse may or may not need to call a neurologist.
A client had an inferior wall myocardial infarction (MI). The nurse notes the clients cardiac rhythm as down below. What action by the nurse is most important?
- A. Assess the clients blood pressure level of consciousness.
- B. Call the health care provider or the Rapid Response Team.
- C. Listen a permit for an emergency temporary pacemaker insertion.
- D. Initiate cardiopulmonary resuscitation (CPR).
Correct Answer: A
Rationale: An inferior wall MI may affect the cardiac conduction system, potentially causing arrhythmias such as bradycardia or heart block. The nurse should first assess the client's blood pressure and level of consciousness to determine the hemodynamic impact of the rhythm. Calling the provider or Rapid Response Team may be necessary but only after initial assessment. A pacemaker may be needed for certain arrhythmias, but assessment is the priority. CPR is not indicated unless the client is in cardiac arrest.