A nurse is assessing a client who has a possible right pneumothorax.
Which of the following findings should the nurse expect?

Choice A rationale:

The prescription for Levothyroxine 75 mcg PO daily at 0600 does not require clarification. It provides clear instructions for the medication, including the drug name, dosage, route, and timing. The administration time (0600) is specific, allowing the nurse to administer the medication accurately.

Choice B rationale:

The prescription for Digoxin 250 PO daily contains an error. The dosage (250) is missing the unit of measurement (e.g., mcg or mg). Without the unit, it is impossible to accurately administer the medication. This prescription needs clarification from the prescriber to ensure safe and precise administration.

Choice C rationale:

The prescription for Acetaminophen 650 mg PO Q6 hours does not require clarification. It provides clear instructions for the medication, including the drug name, dosage (650 mg), route (PO), and frequency (every 6 hours). The dosing interval is appropriate and within the normal range for acetaminophen administration.

Choice D rationale:

The prescription for Ceftriaxone 1 g IV Q 24 hours does not require clarification. It provides clear instructions for the medication, including the drug name, dosage (1 g), route (IV), and frequency (every 24 hours). The dosing interval is appropriate for this antibiotic and allows for effective treatment of infections.

The correct answer is **a. Observe for bruising of the skin.**

Choice A rationale: Observing for bruising of the skin is an appropriate nursing intervention when caring for a client receiving alteplase (recombinant tissue plasminogen activator or rt-PA), a thrombolytic medication used to dissolve blood clots. Alteplase can increase the risk of bleeding, including bruising, as it works to break down the clot. Closely monitoring the client for any signs of bleeding or bruising is crucial to identify and manage potential complications.

Choice B rationale: Administering medications intramuscularly is not recommended when a client is receiving alteplase. Intramuscular injections can increase the risk of bleeding and should be avoided, as alteplase can impair the body's ability to form clots and stop bleeding.

Choice C rationale: Monitoring vital signs every 4 hours is not the appropriate frequency for a client receiving alteplase. Vital signs should be monitored more frequently, typically every 30 minutes to 1 hour, to closely observe for any changes that may indicate bleeding or other complications.

Choice D rationale: Providing a diet low in protein is not a necessary intervention for a client receiving alteplase. Alteplase works by targeting the blood clot and does not require specific dietary modifications. The focus should be on monitoring for bleeding and managing any potential complications, rather than adjusting the client's diet.