CRNE Exam Prep

Category - Changes in Health

A client is rushed to the emergency department after demonstrating signs of acute myocardial infarction. History reveals that the chest pain has not been resolved by sublingual nitroglycerin. The client is started on tissue plasminogen activator by infusion. The nurse caring for the client frequently assesses which of the following parameters?
  1. Serum potassium levels
  2. Oxygen saturation
  3. Pulse rate
  4. Visual acuity
Explanation
Answer: C - The nurse assesses for the client’s pulse rate. Tissue plasminogen activator dissolves existing clots, increasing the client’s risk for excessive bleeding. Internal hemorrhage increases the pulse rate and decreases the blood pressure. Other signs of bleeding include shortness of breath, blood in urine or stool, back pain or abdominal pain, neurological changes, and painful joint movement.
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