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
The correct answer is B. Hip arthroplasty 1 week ago.
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, 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 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 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 B
Explanation
The correct answer is choice B. How to operate the portable suction machine. The nurse should include this information in the teaching because suctioning is often needed to keep the tracheostomy tube and opening free from extra mucus and secretions that come from the lungs and tissue around the stoma. Suctioning can help prevent the tube from becoming plugged and improve breathing.
Choice A is wrong because the nondisposable tracheostomy tube does not need to be changed daily. It can be changed every 1 to 3 months, depending on the type of tube.
Choice C is wrong because the tracheostomy dressing should be changed using sterile technique, not clean technique, to prevent infection.
Choice D is wrong because the tracheostomy tube should not be secured with ties at the back of the neck. The ties should be fastened at the front or side of the neck, and they should be snug but not too tight.
Correct Answer is D
Explanation
The correct answer is choice D. The client is oriented times three.
This means that the client knows who they are, where they are, and what time it is. This indicates a high level of consciousness and a normal Glasgow coma scale (GCS) rating of 15.
Choice A is wrong because the client withdraws from pain.
This means that the client reacts to a painful stimulus by pulling away from it. This indicates a lower level of consciousness and a GCS rating of 4 for motor response.
Choice B is wrong because the client is unable to obey commands.
This means that the client does not follow simple instructions such as moving a limb or opening their eyes. This indicates a lower level of consciousness and a GCS rating of 1 or 2 for motor response.
Choice C is wrong because the client opens eyes to sound.
This means that the client does not open their eyes spontaneously, but only when they hear a loud noise. This indicates a lower level of consciousness and a GCS rating of 3 for eye opening.
The Glasgow coma scale is a clinical tool used to assess the level of consciousness of a person after a brain injury.
It consists of three tests: eye opening, verbal response, and motor response.
Each test has a score range from 1 to 6, with higher scores indicating higher levels of consciousness. The total score ranges from 3 to 15, with lower scores indicating higher risk of death.
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