A nurse is planning care for a client who is to receive alteplase recombinant for a thrombus in the coronary artery.
Which of the following actions should the nurse include in the plan of care?

Observe for bruising of the skin.

Administer medications intramuscularly.

Monitor vital signs every 4 hours

Provide a diet low in protein.

Answer and Explanation

The Correct Answer is A

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.

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Correct Answer is B

No explanation

A. Keep an abduction pillow between the client's legs. B. Elevate the client's affected leg on a pillow when in bed. C. Position the client's knees slightly higher than the hips when up in a chair. D. Raise the head of the client's bed to a high-Fowler's position.

Correct Answer is A

Explanation

Choice A rationale:

Keeping an abduction pillow between the client's legs is a preventive measure to avoid dislocation of the hip prosthesis. This positioning helps maintain the correct alignment of the hip joint, reducing the risk of dislocation. Abduction pillows are commonly used postoperatively after total hip arthroplasty to support proper hip positioning while the patient is in bed.

Choice B rationale:

Elevating the client's affected leg on a pillow when in bed is not recommended after total hip arthroplasty. This position could lead to hip adduction, increasing the risk of prosthesis dislocation. Maintaining abduction (spreading the legs apart) is the key to preventing dislocation, and elevation should be avoided to maintain proper alignment.

Choice C rationale:

Positioning the client's knees slightly higher than the hips when up in a chair is not an appropriate preventive measure for prosthesis dislocation. Proper alignment is crucial, and the client should avoid sitting in low chairs or on low surfaces that could cause the hips to be lower than the knees, potentially leading to dislocation.

Choice D rationale:

Raising the head of the client's bed to a high-Fowler's position is unrelated to preventing prosthesis dislocation. Fowler's position refers to elevating the head of the bed to assist with breathing and facilitate patient comfort. While this position might be suitable for certain respiratory conditions, it has no direct impact on the stability of a hip prosthesis.

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A nurse is planning care for a client who is to receive alteplase recombinant for a thrombus in the coronary artery. Which of the following actions should the nurse include in the plan of care?

Nursing Test Bank

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A nurse is planning care for a client who is to receive alteplase recombinant for a thrombus in the coronary artery.
Which of the following actions should the nurse include in the plan of care?