Question

A 12-lead electrocardiogram (ECG) indicates a ST elevations in leads V1 to V4, for a client who reports having chest pain. The healthcare provider prescribe tissue plasminogen activator (t-PA). Prior to initiating the infusion, which interventions is most important for the nurse to implement?

Answer 1

The most important intervention before starting t-PA is to confirm the absence of contraindications to fibrinolytic therapy and the time of onset of chest pain.

Step-by-step explanation:

The question pertains to the most important nursing intervention prior to initiating tissue plasminogen activator (t-PA) infusion for a client with ST elevations in leads V1 to V4 on a 12-lead electrocardiogram (ECG), suggestive of an acute myocardial infarction (MI). Before administering t-PA, it is crucial to ensure that the client has no contraindications to fibrinolytic therapy. This involves a thorough review of the client's medical history for any recent surgeries, bleeding disorders, or history of hemorrhagic stroke. Additionally, the nurse should confirm the time of onset of chest pain, as t-PA is most effective when administered within a specific timeframe from symptom onset.