A patient is recuperating in the critical care unit following a cardiac catheterization.
IV nitroglycerin and heparin are being administered.
The patient is sedated but responds to verbal instructions.
After changing positions, the patient reports pain at the right groin insertion site.
What action should the nurse take?

Choice A rationale

A blood pressure of 100/60 mm Hg is not typically considered a risk for patients receiving eptifibatide. While eptifibatide can cause hypotension, a blood pressure of 100/60 mm Hg is within normal limits.

Choice B rationale

The presence of hematemesis, or vomiting blood, poses the greatest risk to the patient. Eptifibatide is a glycoprotein IIb/IIIa inhibitor that prevents platelets from clumping together by blocking the action of certain proteins. This can increase the risk of bleeding, including gastrointestinal bleeding, which could manifest as hematemesis.

Choice C rationale

Incontinence with blood in the urine could indicate a urinary tract infection or other urinary system issue, but it is not typically associated with the use of eptifibatide.

Choice D rationale

Unresponsiveness to painful stimuli is a serious symptom that could indicate a number of issues, including neurological damage or severe illness. However, it is not typically associated with the use of eptifibatide.

Choice A rationale

Determining the amount of weight the patient has lost since increasing activity is relevant to the patient’s overall health and progress toward weight loss goals, but it does not directly address the issue of sleep difficulties. Weight loss and improved sleep may not always have a direct cause-and-effect relationship.

Choice B rationale

Inquiring about the patient’s exercise schedule is a reasonable action. It allows the nurse to gather information about the patient’s exercise routine and assess whether it might be contributing to the sleep difficulties. For instance, exercising too close to bedtime can interfere with sleep. Therefore, understanding the timing and intensity of the patient’s exercise can provide valuable insights into potential adjustments that could improve sleep quality.

Choice C rationale

Informing the patient that lifestyle changes often take several weeks to be effective is a general statement that might not address the specific concerns of the patient. While it’s true that lifestyle changes, including exercise, can take time to show results, this does not provide a targeted solution to the patient’s reported difficulty in falling asleep.

Choice D rationale

Encouraging the patient to exercise daily to reduce bedtime wakefulness is not appropriate advice in this scenario. It oversimplifies the issue and may not address the underlying causes of the patient’s sleep difficulties. Additionally, excessive exercise close to bedtime may actually interfere with sleep.