What patient data would indicate to the nurse that the infusion of a thrombolytic agent should be stopped in a patient with an acute myocardial infarction?
Bleeding from the gums.
An increase in blood pressure.
A nonsustained episode of ventricular tachycardia.
Decreased level of consciousness.
The Correct Answer is A
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
Choice A rationale
A 65-year-old male recovering from right lobectomy for treatment of lung cancer is at risk for developing sepsis. Post-surgical patients, especially those with cancer, are at increased risk due to potential infection at the surgical site and a weakened immune system from the cancer and/or its treatment.
Choice B rationale
A 78-year-old female with diabetes mellitus who is recovering from colon surgery is at risk for developing sepsis. Diabetes can impair the immune system, making it harder for the body to fight off infections. Additionally, any surgical procedure carries a risk of infection.
Choice C rationale
A 35-year-old female who is hospitalized with renal insufficiency and has a Foley catheter and central line in place is at risk for developing sepsis. Hospitalized patients, particularly those with invasive devices like catheters and central lines, are at increased risk due to potential introduction of bacteria into the body.
Choice D rationale
A 55-year-old male who is a recent kidney transplant recipient is at risk for developing sepsis. Transplant recipients are often on immunosuppressive therapy to prevent organ rejection, which can leave them more susceptible to infections.
Correct Answer is D
Explanation
The symptoms described - tachycardia, severe dyspnea, diaphoresis, crackles, and profuse, frothy pink sputum - are indicative of acute pulmonary edema, a condition characterized by fluid accumulation in the lungs due to heart failure. In this situation, the Fowler’s position (sitting up at a 45-60 degree angle) with legs lowered is recommended. This position helps to reduce venous return to the heart, thereby decreasing the workload on the heart and helping to alleviate symptoms.
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