A client is admitted to the telemetry unit due to an episode of substernal chest pain.

Diagnostic tests reveal an elevated ST segment on the electrocardiogram (ECG) and an increased cardiac troponin level.

What would be an appropriate initial nursing intervention?

Choice A rationale
Bleeding from the gums is a sign of excessive bleeding, which can be a side effect of thrombolytic therapy. Thrombolytic agents work by dissolving blood clots, but they can also interfere with the body’s normal clotting mechanism, leading to bleeding. If a patient experiences unusual or excessive bleeding, it may be necessary to stop the infusion of the thrombolytic agent.
Choice B rationale
An increase in blood pressure is not typically a reason to stop the infusion of a thrombolytic agent in a patient with an acute myocardial infarction. While blood pressure should be monitored closely during thrombolytic therapy, an increase in blood pressure is not a common side effect.
Choice C rationale
A nonsustained episode of ventricular tachycardia is not typically a reason to stop the infusion of a thrombolytic agent in a patient with an acute myocardial infarction. While arrhythmias can occur during a myocardial infarction, they are not a common side effect of thrombolytic therapy.
Choice D rationale
A decreased level of consciousness can be a sign of many serious conditions, including bleeding in the brain. However, it is not typically a reason to stop the infusion of a thrombolytic agent unless it is accompanied by other signs of excessive bleeding.

Choice A rationale
A Ventricular Septal Defect (VSD) is a hole in the wall separating the two lower chambers of the heart. While it can cause cyanosis, it’s typically not associated with cyanosis during crying or feeding.
Choice B rationale
An Atrioventricular Canal (AVC) defect is a combination of heart problems resulting in a defect in the center of the heart. While it can cause cyanosis, it’s typically not associated with cyanosis during crying or feeding.
Choice C rationale
Tetralogy of Fallot is a congenital heart condition characterized by four anatomical abnormalities of the heart. It is the most common cyanotic heart defect and the most common cause of blue baby syndrome. Cyanosis, which is caused by a lack of oxygen in the blood, is often seen during periods of activity, such as feeding or crying.
Choice D rationale
An Atrial Septal Defect (ASD) is a hole in the wall between the two upper chambers of your heart (atria). While it can cause cyanosis, it’s typically not associated with cyanosis during crying or feeding.