A patient has intra-arterial (art-line) blood pressure monitoring after a myocardial infarction (MI). Following the angioplasty procedure, the nurse notes that the patient'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?
Explanation & Rationale
Choice A reason: Medicating the patient for pain is not the most appropriate immediate action in this situation. While pain management is important, the primary concern should be addressing the significant changes in heart rate and blood pressure, which may indicate a more serious underlying issue.Choice B reason: Allowing the patient to rest quietly is not the appropriate response to the noted changes in vital signs. The increase in heart rate and drop in blood pressure are signs that require immediate investigation and intervention, rather than passive observation.Choice C reason: Assessing the patient for bleeding is the most appropriate action. The increase in heart rate and decrease in blood pressure following an angioplasty procedure are concerning for potential bleeding or hemorrhage, especially if the patient has an intra-arterial line. Quick assessment and intervention are crucial to address any bleeding and stabilize the patient's condition.Choice D reason: Documenting the findings in the chart is necessary, but it should not be the immediate priority. The nurse must first assess and address the potential cause of the changes in vital signs, such as bleeding, before documenting the events.