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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Consuming foods high in bran fiber can help regulate bowel movements and alleviate symptoms of irritable bowel syndrome (IBS). Fiber adds bulk to the stool and can prevent constipation, a common symptom in IBS patients. Adequate dietary fiber intake is generally recommended for individuals with IBS.
Choice B rationale:
Increasing intake of foods high in gluten might worsen symptoms in individuals with gluten sensitivity or celiac disease. Gluten-containing foods can trigger gastrointestinal distress in susceptible individuals and should be avoided if gluten intolerance is present.
Choice C rationale:
Some individuals with IBS are lactose intolerant, which means they have difficulty digesting milk products. Increasing intake of milk products can exacerbate symptoms such as bloating, gas, and diarrhea in these individuals. It is important to assess the client's tolerance to lactose-containing foods before recommending their consumption.
Choice D rationale:
Sweetening foods with fructose corn syrup may worsen symptoms in individuals with IBS. Fructose is a type of sugar that can cause gastrointestinal distress in some people, especially those with fructose malabsorption. Recommending sweeteners with low fructose content would be more appropriate for individuals with IBS.
Correct Answer is D
Explanation
Explanation: MRSA is a type of bacteria that is resistant to many antibiotics and can cause serious infections in various parts of the body. The nurse should wear a gown when assisting the client with personal hygiene to prevent contact transmission of MRSA to other clients or staff members. The nurse should also wear gloves and a mask and perform hand hygiene before and after contact with the client or their environment. The nurse should remove personal protective equipment before leaving the client's room and dispose of it properly to avoid contamination of other areas or surfaces. Negative air pressure is not required for MRSA isolation because it is not an airborne infection. The client's visitors should not be restricted, but they should be educated on the proper use of personal protective equipment and hand hygiene when visiting the client.
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