The nurse is caring for a client with weak pedal pulses, absent hair on bilateral legs, and a full-thickness wound on the right lateral malleolus with defined margins, including a minimal amount of serous exudate.

Which of the following interventions is contraindicated?

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.

Chronic stable angina, also known as angina pectoris, is a type of chest pain that occurs when the heart muscle doesn’t get enough oxygen. It is often triggered by physical activity or emotional stress and is usually relieved by rest or medication such as nitroglycerin. Therefore, a patient statement that the pain goes away after taking a nitroglycerin tablet would help confirm a previous diagnosis of chronic stable angina.