A client is receiving an infusion of alteplase for treatment of an anterior-septal myocardial infarction. The nurse assesses the client and finds them to be disoriented to person, place, and time. What action by the nurse is best?

Obtain a STAT electrocardiogram (EKG).

Call the primary health care provider immediately.

Prepare the client for percutaneous cardiac intervention (PCI).

Obtain STAT cardiac enzymes.

Answer and Explanation

The Correct Answer is B

A. Obtain a STAT electrocardiogram (EKG).: An EKG evaluates cardiac rhythm and ongoing ischemic changes but does not assess neurological status. New disorientation during alteplase infusion raises concern for intracranial hemorrhage. Cardiac monitoring is important, but it does not address the immediate neurologic emergency suggested by acute mental status changes.

B. Call the primary health care provider immediately.: Alteplase is a fibrinolytic that increases the risk of bleeding, including intracranial hemorrhage. Sudden confusion and disorientation are early neurologic signs that may indicate cerebral bleeding. Immediate provider notification is critical so the infusion can be stopped and urgent neuroimaging, such as a CT scan, can be initiated to evaluate for hemorrhage.

C. Prepare the client for percutaneous cardiac intervention (PCI).: PCI is considered if thrombolytic therapy fails or if there is persistent ischemia. Disorientation is not an indication of failed reperfusion but rather a potential bleeding complication. Preparing for PCI would delay evaluation of a potentially life-threatening neurologic event.

D. Obtain STAT cardiac enzymes.: Cardiac enzymes help evaluate myocardial injury but are not useful in assessing acute neurologic deterioration. Elevated enzymes confirm myocardial infarction but do not explain sudden changes in mental status. The priority is evaluating for a hemorrhagic complication related to thrombolytic therapy.

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Correct Answer is C

Explanation

A. Allow the client to rest quietly: While rest is generally beneficial, the combination of tachycardia and hypotension suggests possible acute complications such as bleeding or cardiogenic shock. Simply allowing the client to rest does not address the underlying cause and could delay life-saving interventions.

B. Document the findings in the chart: Documentation is important for communication and legal purposes, but it is not an immediate intervention. The nurse must first assess the client for potential causes of hemodynamic instability before charting.

C. Assess the client for bleeding: A drop in blood pressure with a compensatory increase in heart rate may indicate hypovolemia from internal or external bleeding, especially if the client has invasive lines or recent procedures. Prompt assessment and intervention are crucial to prevent shock and organ damage.

D. Medicate the client for pain: Pain management is important, but administering analgesics in the context of hypotension and tachycardia could worsen hemodynamic instability. The priority is identifying and treating the underlying cause before giving medications that may further lower blood pressure.

A. A B. B

Correct Answer is B

Explanation

A. The rhythm strip shown in A exhibits a regular underlying rhythm interrupted by a Premature Ventricular Contraction (PVC), which is a wide, bizarre QRS complex occurring earlier than expected. While PVCs can cause palpitations, they do not typically present as a sustained "rapid, irregular" heart rate with a total absence of P-waves across the entire strip.

B. The rhythm strip in B represents Atrial Fibrillation (AFib), characterized by a "normally irregular" ventricular response and the replacement of distinct P-waves with chaotic fibrillatory waves. In AFib, the atria quiver rather than contract, leading to a significant pulse deficit because not every electrical impulse results in a ventricular contraction strong enough to produce a peripheral pulse.

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A client is receiving an infusion of alteplase for treatment of an anterior-septal myocardial infarction. The nurse assesses the client and finds them to be disoriented to person, place, and time. What action by the nurse is best?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client has intra-arterial blood pressure monitoring after a myocardial infarction. The nurse notes that the client's 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?

Correct Answer is C

Explanation

A nurse in an urgent care center is assessing a client who reports sudden-onset palpitations, fatigue, and dizziness. The nurse assesses a rapid, irregular heart rate with a significant pulse deficit and no definitive P-waves. Which dysrhythmia does the nurse expect to find on the cardiac monitor?

Correct Answer is B

Explanation

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