The nurse is administering a thrombolytic agent to a patient having an acute myocardial infarction. Which patient data indicates that the nurse should stop the drug infusion?.
A brief episode of ventricular tachycardia.
Bleeding from the gums.
Decreased level of consciousness.
An increase in blood pressure.
The Correct Answer is B
Choice A rationale:
A brief episode of ventricular tachycardia, or a rapid heart rate, can occur in patients receiving thrombolytic therapy. However, it is not typically a reason to stop the drug infusion.
Choice B rationale:
Bleeding from the gums can be a sign of excessive bleeding, which is a major risk of thrombolytic therapy. This would be a reason to stop the drug infusion.
Choice C rationale:
A decreased level of consciousness can have many causes and is not specifically associated with thrombolytic therapy.
Choice D rationale:
An increase in blood pressure is not typically a reason to stop thrombolytic therapy.
So, the correct answer is B, after analyzing all choices.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D","F"]
Explanation
Choice A rationale:
The client’s temperature decreased from 37.6°C to 36.8°C1. This is within the normal body temperature range of 36.5°C to 37.2°C2, so it does not require further action.
Choice B rationale:
The client’s oxygen saturation decreased from 95% to 88%1. Normal pulse oximetry values are typically above 95%2. This decrease could indicate that the client is not getting enough oxygen, which requires further action.
Choice C rationale:
The client’s blood pressure increased from 108/50 mm Hg to 138/80 mm Hg. Normal blood pressure for adults is below 120/80 mm Hg. This increase could indicate worsening heart failure, which requires further action.
Choice D rationale:
The client’s weight increased from 80 kg to 82.1 kg. Rapid weight gain may be a sign of fluid retention, a common symptom of heart failure. This requires further action.
Choice E rationale:
The client’s urine output decreased from 480 mL/8 hr to 320 mL/8 hr.However it is still above 30ml/hr signifying normal renal function
Choice F rationale:
On Day 4, the client’s breath sounds were scattered, and crackles were heard bilaterally. This could indicate fluid accumulation in the lungs, a common symptom of heart failure. This requires further action.
So, the correct answer is Choices B, C, D, and F, after analyzing all choices.
Correct Answer is B
Explanation
Choice A rationale:
ST segment changes on an ECG are not typically associated with chronic constrictive pericarditis.
Choice B rationale:
Jugular venous distention (JVD) is a common sign of chronic constrictive pericarditis. If JVD is not present, it may indicate that the therapies are effective.
Choice C rationale:
While the sedimentation rate can indicate inflammation, it is not specific to chronic constrictive pericarditis.
Choice D rationale:
The presence of a paradoxical pulse is not typically associated with chronic constrictive pericarditis.
So, the correct answer is B, after analyzing all choices.
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