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

Answer and Explanation

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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Correct Answer is A

Explanation

The nurse should include the statement that rifampin can cause the client's urine to turn orange. Rifampin is an antibiotic commonly used to treat tuberculosis and other bacterial infections. One of its common side effects is discoloration of bodily fluids, including urine, saliva, sweat, and tears. This discoloration is harmless and is not a cause for concern. Informing the client about this side effect helps prevent unnecessary worry or alarm.

"You should take this medication with food" (B) is not specifically related to rifampin. However, taking rifampin with food can help reduce gastrointestinal side effects such as stomach upset or nausea.

"This medication can cause insomnia" (C) is not a common side effect of rifampin. Insomnia is more commonly associated with certain other medications or medical conditions.

"You should take a stool softener with this medication" (D) is not necessary for rifampin. Stool softeners are typically used to alleviate constipation, but rifampin does not commonly cause constipation as a side effect.

Therefore, the nurse should primarily include the statement that rifampin can cause the client's urine to turn orange.

A. Hypoactive bowel sounds B. Sweating C. Respiratory distress D. Urinary retention E. Bradycardia

Correct Answer is ["B","C","E"]

Explanation

Neostigmine is a medication classified as an acetylcholinesterase inhibitor. It is commonly used to treat myasthenia gravis and to reverse the effects of non-depolarizing neuromuscular blocking agents used during surgery. Adverse reactions to neostigmine are related to its cholinergic effects, which result from increased acetylcholine levels in the body.

Let's go through the options:

A. Hypoactive bowel sounds: Neostigmine can actually increase gastrointestinal motility and may cause increased bowel sounds or even diarrhea, not hypoactive bowel sounds. Therefore, hypoactive bowel sounds are not an adverse reaction to neostigmine.

B. Sweating: Sweating is a cholinergic effect and can be an adverse reaction to neostigmine. Increased sweating is a common sign of cholinergic stimulation.

C. Respiratory distress: Respiratory distress can occur as an adverse reaction to neostigmine, particularly if the client has a history of asthma or other respiratory conditions. Neostigmine can cause bronchoconstriction and excessive secretions, leading to respiratory distress.

D. Urinary retention: Neostigmine is actually used to treat urinary retention by increasing bladder contraction. Therefore, urinary retention is not an adverse reaction to neostigmine.

E. Bradycardia: Bradycardia (slow heart rate) is a significant adverse reaction to neostigmine due to its cholinergic effects on the heart. Increased acetylcholine levels can lead to excessive stimulation of the vagus nerve, resulting in bradycardia.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching for a client who has a new prescription for rifampin. Which of the following statements should the nurse include?

Correct Answer is A

Explanation

A nurse is caring for a client who is receiving neostigmine. Which of the following manifestations should the nurse identify as an adverse reaction to the medication? (Select all that apply.)

Correct Answer is ["B","C","E"]

Explanation

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