A 58-year-old patient is admitted to the coronary care unit with unstable angina and receives thrombolytic therapy. Which nursing action is the highest priority?

Post-thrombolytic therapy requires vigilant monitoring for bleeding complications, especially intracranial hemorrhage, which is life-threatening. Other options are less critical or inappropriate for immediate post-thrombolytic care.

Core Nursing Explanation Key Concept Analysis: This question tests the priority nursing action for a patient immediately following thrombolytic therapy. Thrombolytics (e.g., alteplase, reteplase) are "clot-busting" drugs used in acute coronary syndromes like unstable angina or myocardial infarction (MI). Their mechanism is to dissolve the fibrin mesh of a thrombus, but this action is non-specific and can also disrupt normal hemostasis, leading to a significant risk of bleeding. The most feared complication is intracranial hemorrhage (ICH), which is life-threatening. Therefore, the immediate post-therapy period demands vigilant monitoring for bleeding. Answer Rationale: Key Point! The highest priority is always patient safety from the most immediate and severe threat. After thrombolytic administration, the greatest risk is serious bleeding. Option ① directly addresses this by instructing to "Monitor for signs of bleeding and assess neurological status every 15 minutes." This combines systemic bleeding surveillance (e.g., at IV sites, gums, urine, stool) with specific monitoring for the most catastrophic bleed—intracranial hemorrhage. A change in neurological status (e.g., sudden headache, vision changes, weakness, altered level of consciousness) could be the first sign of ICH. Distractor Analysis:
Watch out for confusion! Option ②, "Encourage early ambulation to prevent deep vein thrombosis," is contraindicated in the immediate post-thrombolytic period. The patient is at high risk for bleeding, and ambulation could increase the risk of falls and injury. DVT prophylaxis in this acute setting would typically involve pharmacological (e.g., heparin) or mechanical (sequential compression devices) methods, not early ambulation.
Option ③, "Administer sublingual nitroglycerin for chest pain relief," is a supportive measure, not the priority. While chest pain management is important, the question asks for the priority action after receiving thrombolytic therapy. The life-threatening risk introduced by the therapy itself (bleeding) takes precedence over managing the original symptom.
Option ④, "Obtain a 12-lead ECG every 4 hours to monitor cardiac rhythm," is a standard monitoring activity but not the most urgent priority. Cardiac monitoring is continuous in a CCU. While serial ECGs are important to assess for reperfusion (e.g., resolution of ST-segment elevation) or re-infarction, they do not address the acute, drug-induced risk that requires immediate and frequent assessment. Related Concepts: The nursing care for a patient receiving thrombolytics revolves around the "Two R's": Reperfusion (monitoring for resolution of chest pain and ST segments on ECG) and Risk of Bleeding. All invasive procedures (e.g., IM injections, arterial sticks) should be minimized. Vital signs and neurological checks are performed frequently (e.g., every 15 min x 1 hour, then every 30 min x 1 hour, then hourly).

Nursing Clinical Practice Guide Clinical Scenario: You are the nurse in the CCU. Mr. Johnson, 58, just received a bolus and infusion of a thrombolytic agent for his unstable angina. The physician's order states: "Monitor for bleeding, neuro checks q15min x 1hr." Nursing Intervention Strategy: 1. Assessment: Immediately after the infusion, perform a focused assessment. Check all IV sites for infiltration or hematoma. Assess skin for petechiae or bruising. Ask the patient about headache, vision changes, or neck stiffness. Perform a baseline neurological assessment using a tool like the NIH Stroke Scale or simply check level of consciousness (LOC), pupil response, and motor strength. 2. Safety & Precautions: Apply pressure to any venipuncture sites for at least 10 minutes. Use electric razors, not blades. Use a soft-bristle toothbrush. Instruct the patient to avoid blowing his nose forcefully or straining during bowel movements. 3. Monitoring: Set a timer for 15-minute intervals. Each check includes: asking "Do you have a headache?"; assessing speech clarity and facial symmetry; checking grip strength bilaterally; inspecting gums, urine (for hematuria), and stool (for melena). Document meticulously. 4. Patient/Family Education: Explain why these frequent checks are necessary. "The medicine is working to open the artery in your heart, but we need to watch very closely for any signs of bleeding, which is a possible side effect." Nursing Procedure & Medication Flow During/Post Thrombolytic Administration:
1. Access: Maintain two patent IV lines before starting therapy—one dedicated for the thrombolytic, another for other medications.
2. Administration: Administer the thrombolytic via an IV pump per protocol (often a bolus followed by an infusion over 60-90 minutes). Do not mix other medications in the same line.
3. Contraindications/Actions: Know absolute contraindications to thrombolytics (active internal bleeding, history of hemorrhagic stroke, recent major surgery/trauma). If bleeding occurs, be prepared to stop the infusion immediately, notify the physician, and have protamine sulfate (for heparin reversal) or cryoprecipitate/fresh frozen plasma (for fibrinogen replacement) available per protocol.
4. Post-Therapy: Avoid IM injections, arterial punctures, and unnecessary venipuncture. If lab draws are needed, use existing IV lines if possible. A Word from Your Senior Nurse "In the high-stakes environment of the CCU, your role shifts from just task-doer to vigilant guardian. Giving a thrombolytic is a calculated risk to save heart muscle. Your job is to manage that risk. Those q15min neuro checks aren't just a box to tick—they are your direct window into the patient's brain. A sudden complaint of 'the worst headache of my life' is a RED ALERT. On the NCLEX, they love to test this priority: the complication of the treatment often trumps the original disease in the immediate aftermath. Always ask yourself, 'What is the most dangerous thing that could happen right now because of what we just did?' That's your priority."