A nurse is caring for a client who received alteplase 12 hr ago following a thrombotic stroke. The nurse should monitor the client for which of the following adverse effects?
Laryngospasm
Polycythemia
Hemorrhage
Steatorrhea
The Correct Answer is C
A. Laryngospasm: Laryngospasm is not a commonly associated adverse effect of alteplase administration. It is more commonly associated with airway irritants or allergic reactions.
B. Polycythemia: Polycythemia, or an abnormally high red blood cell count, is not a typical adverse effect of alteplase administration. Alteplase is a thrombolytic agent used to dissolve blood clots and is not associated with increasing red blood cell production.
C. Hemorrhage: Hemorrhage, or bleeding, is the most significant adverse effect associated with alteplase administration. Alteplase works by promoting fibrinolysis and can increase the risk of bleeding, including intracranial hemorrhage, particularly in the context of thrombolytic therapy for stroke.
D. Steatorrhea: Steatorrhea, or fatty stools, is not a commonly associated adverse effect of alteplase administration. It is more commonly associated with malabsorption disorders or pancreatic insufficiency.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Pedal edema is not typically associated with an acute infusion reaction to amphotericin B.
B. A dry cough is not typically associated with an acute infusion reaction to amphotericin B.
C. Fever is a common manifestation of an acute infusion reaction to amphotericin B, indicating a systemic inflammatory response.
D. Hyperglycemia is not typically associated with an acute infusion reaction to amphotericin B.
Correct Answer is B
Explanation
A. Heart rate is important to monitor, but it is not the most immediate indicator of a life-threatening complication from midazolam. Changes in heart rate can occur, but they are usually secondary to respiratory issues.
B. Oxygen saturation is the priority because midazolam, a benzodiazepine, can cause respiratory depression and airway compromise. Monitoring oxygenation allows for rapid detection of hypoxia, which is the most immediate risk during moderate sedation.
C. Level of consciousness should be assessed, as midazolam causes sedation and can lead to oversedation. However, airway and breathing take priority over neurological assessment in this situation.
D. Temperature is not significantly affected by midazolam and is not an immediate concern during moderate sedation. It is therefore the lowest priority among the options provided.
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