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?

Choice A reason

Act as a spokesperson to provide information to the media in inappropriate. During a disaster, the nurse manager or designated hospital spokesperson usually handles communication with the media. The unit nurse's primary focus is on patient care and ensuring the safety and well-being of the clients on their unit.

Choice B reason

Recommending to the provider a list of clients for early discharge is the action that should be taken by the nurse. During a disaster, the responsibility of the unit nurse includes recommending to the healthcare provider a list of clients who may be considered for early discharge. This decision is based on the nurse's assessment of the clients' conditions and the need to create additional capacity for incoming patients who require urgent medical attention.

Choice C reason:

Determining the need for additional providers is inappropriate. The determination of the need for additional providers during a disaster is usually made at a higher level, such as by the nursing supervisor, nurse manager, or hospital administration. The unit nurse may collaborate with the nursing leadership to assess staffing needs and provide input, but the final decision is typically made at a higher level.

Choice D reason

Deciding which clients should be transported for a higher level of care is not the responsibility of the nurse. Decisions about transferring clients for a higher level of care during a disaster are usually made collaboratively among the healthcare team, including the healthcare providers and nursing leadership. The unit nurse may provide valuable input about the clients' conditions, but the decision is not solely the responsibility of the unit nurse.

The correct answer is choice D, a noncoring needle.

A noncoring needle is a special type of needle that has a beveled tip and a side hole. It is designed to prevent damage to the port’s septum, which is the soft silicone top that serves as the vein access point.

A noncoring needle also reduces the risk of infection and clotting.

Choice A is wrong because a butterfly needle is a small, winged needle that is used for peripheral venous access, not for accessing a port. A butterfly needle can damage the port’s septum and cause leakage or infection.

Choice B is wrong because an angiocatheter is a thin, plastic tube that is inserted into a vein using a needle.

It is used for short-term IV therapy, not for accessing a port. An angiocatheter can also damage the port’s septum and cause complications.

Choice C is wrong because a 25-gauge needle is too small to access a port.

A 25-gauge needle is typically used for subcutaneous injections, not for intravenous injections. A 25-gauge needle can also clog the port or cause hemolysis (breakdown of red blood cells).

Normal ranges for ports vary depending on the type and size of the port, but generally they have a reservoir diameter of 1.5 to 2.5 cm, a catheter length of 40 to 60 cm, and a catheter diameter of 0.8 to 1.2 mm. Ports are usually flushed with saline or heparin solution every 4 to 6 weeks when not in use to prevent clotting.