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.

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

The correct answer is choiceD. Remind the client to use the incentive spirometer.

Choice A rationale:

Observing the position of the suspended weight requires clinical judgment to ensure proper alignment and effectiveness of the traction, which is beyond the scope of practice for assistive personnel.

Choice B rationale:

Checking the client’s pedal pulse on the right leg involves assessing circulation, which is a clinical task that should be performed by a licensed nurse.

Choice C rationale:

Asking the client to describe her pain involves pain assessment, which requires clinical judgment and should be done by a nurse.

Choice D rationale:

Reminding the client to use the incentive spirometer is a task that can be delegated to assistive personnel as it involves reinforcing previously taught instructions without requiring clinical judgment.

A. Educating clients about contraindications to specific immunizations. B. Using an electronic messaging system to remind clients when to take medications. C. Providing clients with information about the benefits of exercise. D. Helping clients understand health screenings covered by their insurance plans.

Correct Answer is B

Explanation

The correct answer is choice b. Using an electronic messaging system to remind clients when to take medications.

Choice A rationale:

Educating clients about contraindications to specific immunizations is an example of primary prevention, which aims to prevent disease before it occurs.

Choice B rationale:

Using an electronic messaging system to remind clients when to take medications is an example of tertiary prevention. It helps manage an existing condition (HIV) by ensuring adherence to treatment, thereby preventing complications and improving quality of life.

Choice C rationale:

Providing clients with information about the benefits of exercise is generally considered primary prevention, as it aims to promote overall health and prevent disease.

Choice D rationale:

Helping clients understand health screenings covered by their insurance plans is an example of secondary prevention, which focuses on early detection and treatment of disease.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is developing a care plan for a client who is in Buck’s traction and is scheduled for surgery for a fractured femur of the right leg. Which of the following interventions should the nurse delegate to an assistive personnel?

Correct Answer is D

Explanation

A newly licensed nurse working at an HIV clinic is reviewing the responsibilities of her position at the clinic. Which of the following tasks should the nurse identify as tertiary prevention?

Correct Answer is B

Explanation

A nurse is caring for a client who has experienced a stroke and is moving in with an adult child. Which of the following actions should the nurse encourage the client and family to take as they adjust to their new roles?

A nurse is assessing a child who has bacterial pneumonia. Which of the following manifestations should the nurse expect?

A nurse in a mental health clinic receives a request from a client who is undergoing psychotherapy to obtain a copy of the therapist’s notes. Which of the following responses should the nurse make?

A nurse is caring for a client who has a placenta previa. Which of the following findings should the nurse expect?

A nurse is teaching a prenatal class about infection prevention at a community center. Which of the following statements by a client indicates an understanding of the teaching?

A nurse is reviewing the laboratory data of a client who received 2 units of packed RBCs. Which of the following laboratory findings should the nurse expect following the transfusion?

A nurse has just received change-of-shift report for four clients. Which of the following clients should the nurse assess first?

A nurse is teaching a client who has chronic pain about avoiding constipation from opioid medications. Which of the following information should the nurse include in the teaching?

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?