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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","E"]
Explanation
The nurse should monitor the following laboratory tests to determine the effectiveness of epoetin alfa:
B. Hemoglobin: Epoetin alfa is a medication used to treat anemia by stimulating red blood cell production. Monitoring hemoglobin levels can help assess if the medication is effectively increasing red blood cell production and improving anemia.
E. Iron: Iron is essential for red blood cell production. Monitoring iron levels can help determine if the client has adequate iron stores to support the increased production of red blood cells stimulated by epoetin alfa.
The other options listed, A. Thyroid-stimulating hormone, C. Blood glucose, and D. Alanine aminotransferase, are not directly related to the effectiveness of epoetin alfa in treating anemia. Thyroid-stimulating hormone is related to thyroid function, blood glucose is related to blood sugar control, and alanine aminotransferase is related to liver function. While these tests may be important for monitoring the overall health of the client, they are not specific indicators of the effectiveness of epoetin alfa.
Correct Answer is B
Explanation
When caring for a client receiving heparin by continuous IV infusion for the treatment of venous thrombosis, the nurse should monitor the client's aPTT (Activated Partial Thromboplastin Time) to titrate the heparin dose.
Heparin is an anticoagulant medication used to prevent and treat blood clots. The aPTT is a coagulation test that measures the time it takes for the blood to clot when a specific activator is added. Monitoring the aPTT is a standard method for assessing the anticoagulant effect of heparin and ensuring that the client's blood remains within the desired therapeutic range.
The therapeutic range for aPTT while on heparin therapy varies depending on the indication and the client's condition but is generally maintained at a level that prolongs the clotting time enough to prevent and treat thrombosis while avoiding excessive bleeding risk.
Let's go through the other options:
A. Platelet function assay: While monitoring platelet function is essential for assessing overall hemostasis and platelet function, it is not specifically used for titrating heparin doses. Platelet function assays are more commonly used to assess the function of platelets in the context of platelet disorders or antiplatelet medication therapy.
C. INR (International Normalized Ratio): The INR is used to monitor the effect of vitamin K antagonist anticoagulants, such as warfarin, and is not the appropriate test for monitoring heparin therapy.
D. Amylase: Amylase is an enzyme produced by the pancreas and salivary glands and is not relevant for monitoring heparin therapy. Elevated amylase levels are typically associated with pancreatitis and not related to heparin treatment.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.