A nurse in an emergency department is reviewing the medical record of a client who is having an acute myocardial infarction.
Which of the following findings places the client at risk if he receives alteplase?
Family history of malignant hypertension.
Hip arthroplasty 1 week ago.
Chronic obstructive pulmonary disease.
Acute renal failure 6 months ago.
The Correct Answer is B
Alteplase is a drug that dissolves blood clots by converting plasminogen to plasmin. It can be used for acute ischemic stroke, but it has some contraindications that depend on the indication and the type of administration of the drug. Some common contraindications for alteplase are hypersensitivity, active internal bleeding, a history of intracranial hemorrhage, bleeding disorders, and high blood pressure. Other contraindications may vary depending on the specific condition and the time window of treatment. Alteplase can cause serious or fatal bleeding as a side effect.
Choice A is wrong because a family history of malignant hypertension is not an absolute contraindication for alteplase, although uncontrolled hypertension (>185 mmHg SBP or >110 mmHg DBP) is.
Choice C is wrong because chronic obstructive pulmonary disease is not a contraindication for alteplase, although it may increase the risk of pulmonary hemorrhage.
Choice D is wrong because acute renal failure 6 months ago is not a contraindication for alteplase, although the current use of direct thrombin inhibitors or direct factor Xa inhibitors is.
Normal ranges for blood pressure are <120/80 mmHg for normal, 120-129/<80 mmHg for elevated, 130-139/80-89 mmHg for stage 1 hypertension, and ≥140/≥90 mmHg for stage 2 hypertension.
Normal ranges for platelet count are 150,000 to 450,000 platelets per microliter of blood.
Normal ranges for INR are 0.8 to 1.2 for people who are not taking blood thinners and 2 to 3 for people who are taking warfarin.
Normal ranges for aPTT are 25 to 35 seconds for people who are not taking blood thinners and 46 to 70 seconds for people who are taking heparin.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
This is because the nurse should assess the client’s level of mobility, strength, and coordination before repositioning them to prevent injury and promote comfort. The nurse should also use appropriate assistive devices, such as a drawsheet, a trapeze bar, or a mechanical lift, to facilitate safe repositioning and reduce the risk of skin breakdown and pressure ulcers.
Choice A is wrong because raising the side rails on both sides of the client’s bed during repositioning can increase the risk of falls and entrapment.
The nurse should only raise the side rail on the opposite side of the bed from where they are working and lower it when they are done.
Choice B is wrong because repositioning the client without assistive devices can cause strain and injury to both the nurse and the client.
The nurse should use assistive devices that are appropriate for the client’s condition and weight.
Choice C is wrong because discussing the client’s preferences for determining a repositioning schedule is not a priority action when preparing to reposition a client who had a stroke.
The nurse should follow the facility’s protocol for repositioning frequency, which is usually every 2 hours, and adjust it according to the client’s needs and comfort.
The nurse should also involve the client in the care plan and respect their preferences whenever possible.
Correct Answer is B
Explanation
This method involves feeling the radial pulse while inflating and deflating the cuff.
The systolic pressure is estimated by noting the pressure at which the pulse disappears and reappears. The diastolic pressure is not measured by this method, but it can be useful when the sounds are difficult to hear.
Choice A is wrong because applying the largest cuff available can result in a falsely low reading. The cuff size should be appropriate for the client’s arm circumference.
Choice C is wrong because placing the arm above the level of the client’s heart can also cause a falsely low reading. The arm should be at the level of the heart for an accurate measurement.
Choice D is wrong because deflating the cuff quickly can lead to missing or skipping sounds, resulting in an inaccurate reading. The cuff should be deflated slowly and evenly.
Normal ranges for blood pressure vary depending on age, sex, and health conditions, but generally, a systolic pressure below 120 mmHg and a diastolic pressure below 80 mmHg are considered normal for adults.
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