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 D
No explanation
Correct Answer is C
Explanation
Choice A rationale:
Checking the medical record for prior blood glucose test results is a task that can be delegated to the assistive personnel (AP). It provides relevant information for the nurse to assess the client's current condition. However, it is not the most crucial step in ensuring the safe performance of the blood glucose test.
Choice B rationale:
Asking the client if she has taken her antidiabetic medication today is important, but this task is better suited for the nurse, as it requires accurate communication with the client about their medication history and adherence. Delegating this task to the AP may lead to potential misunderstandings or errors in the information provided.
Choice C rationale:
The nurse should determine if the AP has the necessary skills and competence to perform the blood glucose test. Delegating tasks based on the competency of the staff member ensures the safety and well-being of the client. If the AP is not skilled in performing the test, the nurse should assign the task to someone else or perform the test personally.
Choice D rationale:
The nurse should not directly perform the blood glucose test if it can be safely delegated to the AP. Delegating appropriate tasks to competent staff members allows nurses to focus on more complex aspects of client care and ensures efficient use of resources within the healthcare team.
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