A nurse in the emergency department is planning care for a client who had a myocardial infarction and is receiving thrombolytic therapy with an WV infusion of alteplase. Which of the following interventions should the nurse include in the plan?
Administer aspirin instead of acetaminophen for fever
Ambulate the client as often as tolerated
Administer a sodium phosphate enema for constipation
Monitor for changes in level of consciousness
The Correct Answer is D
When planning care for a client who had a myocardial infarction and is receiving thrombolytic therapy with an IV infusion of alteplase, the nurse should include the intervention of monitoring for changes in the client's level of consciousness.
Alteplase is a thrombolytic medication used to break down blood clots in certain medical emergencies, such as acute myocardial infarction (heart attack) or ischemic stroke. One of the potential complications of thrombolytic therapy, including alteplase, is bleeding. The medication's action of breaking down blood clots can also affect the body's natural clotting mechanisms, increasing the risk of bleeding.
Bleeding in the brain is a severe and potentially life-threatening complication associated with thrombolytic therapy. Therefore, it is essential for the nurse to closely monitor the client for any signs of intracranial bleeding, such as changes in the level of consciousness, confusion, severe headache, slurred speech, or weakness on one side of the body.
Let's go through the other options:
A. Administer aspirin instead of acetaminophen for fever: While aspirin is commonly used in the management of myocardial infarction, it is not specifically indicated for fever. Acetaminophen is the preferred antipyretic medication for fever management in most cases, and it does not interfere with the action of thrombolytic therapy.
B. Ambulate the client as often as tolerated: While early ambulation is beneficial for clients with myocardial infarction, it may not be appropriate during thrombolytic therapy. Thrombolytic therapy carries an increased risk of bleeding, and ambulation may be limited or contraindicated during the treatment period, depending on the client's overall condition and bleeding risk.
C. Administer a sodium phosphate enema for constipation: The administration of a sodium phosphate enema is not a specific intervention related to thrombolytic therapy or myocardial infarction. Bowel management is important for client comfort and overall well-being, but it is not a priority intervention in the immediate care of a client undergoing thrombolytic therapy.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["18.8"]
Explanation
To calculate the rate at which the IV pump should deliver dopamine, we can follow these steps:
Step 1: Convert the weight of the client from pounds to kilograms.
220 lb ÷ 2.2 = 100 kg (rounded to the nearest whole number)
Step 2: Calculate the total dose of dopamine per minute.
5 mcg/kg/min × 100 kg = 500 mcg/min
Step 3: Convert the dose from micrograms (mcg) to milligrams (mg).
500 mcg/min ÷ 1000 = 0.5 mg/min
Step 4: Determine the infusion rate in milliliters per hour (mL/hr).
The total volume of the solution is 250 mL.
The total dose of dopamine is 400 mg.
So, the infusion rate is (0.5 mg/min ÷ 400 mg) × 250 mL = 0.3125 mL/min.
Step 5: Convert the infusion rate from mL/min to mL/hr.
0.3125 mL/min × 60 min/hr = 18.75 mL/hr (rounded to the nearest tenth).
Therefore, the nurse should set the IV pump to deliver 18.8 mL/hr (rounded to the nearest tenth).
Correct Answer is A
Explanation
A client with a magnesium level of 3.2 mEq/L has a higher-than-normal magnesium level, indicating hypermagnesemia. The nurse should expect to administer calcium gluconate.
Calcium gluconate is the antidote for hypermagnesemia, as it works to antagonize the effects of magnesium on the body. By administering calcium gluconate, the nurse can help counteract the effects of excess magnesium and normalize the client's magnesium levels.
Let's go through the other options:
B. Calcitonin: Calcitonin is not used to treat hypermagnesemia. Calcitonin is a hormone that regulates calcium and phosphorus levels in the body. It is used in certain conditions, such as hypercalcemia (high calcium levels), but it is not indicated for hypermagnesemia.
C. Magnesium oxide: Magnesium oxide is a form of magnesium supplement, and it is not appropriate for a client with hypermagnesemia, as it would further increase the magnesium level, exacerbating the condition.
D. Magnesium sulphate: Magnesium sulfate is also not appropriate for a client with hypermagnesemia, as it would further elevate the magnesium levels in the body. Magnesium sulfate is often used to treat magnesium deficiency or as a tocolytic agent to prevent premature labor.
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