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

Explanation

Choice A rationale:

Sitting in high-Fowler's position during the feeding is actually a preventive measure against aspiration. High-Fowler's position, which involves sitting the patient upright at a 90-degree angle, reduces the risk of aspiration by promoting proper digestion and preventing the regurgitation of gastric contents into the lungs.

Choice B rationale:

A history of gastroesophageal reflux disease (GERD) puts the client at risk for aspiration. GERD is a chronic condition in which stomach acid frequently flows back into the esophagus, potentially reaching the throat and lungs, increasing the risk of aspiration during enteral feedings. Aspiration pneumonia, a serious complication, can develop if stomach contents enter the lungs.

Choice C rationale:

A residual of 65 mL 1 hr postprandial indicates that a significant amount of the feeding solution has not been absorbed, raising concerns about delayed gastric emptying. While this situation might require monitoring and adjustments to the feeding regimen, it does not directly increase the risk of aspiration. Aspiration risk is more related to the reflux of stomach contents into the airways.

Choice D rationale:

Receiving a high-osmolarity formula alone does not directly increase the risk of aspiration. High-osmolarity formulas might require careful administration and monitoring to prevent complications, but aspiration risk is more closely associated with the client's underlying conditions, such as GERD.

A. Prepare to assist with intubation. B. Prepare a cool mist tent. C. Suction the child's oropharynx. D. Obtain a throat culture.

Correct Answer is A

Explanation

Choice A rationale:

Preparing to assist with intubation is the appropriate action for a nurse caring for a child with suspected epiglottitis. Epiglottitis is a medical emergency where the airway can become severely compromised due to inflammation of the epiglottis. Intubation ensures a secure airway, allowing the child to breathe and preventing respiratory distress.

Choice B rationale:

Preparing a cool mist tent is not the priority in suspected epiglottitis. While humidified air can provide comfort for respiratory distress, it does not address the potential for airway obstruction. Intubation takes precedence in this critical situation.

Choice C rationale:

Suctioning the child's oropharynx may worsen the condition in suspected epiglottitis. Suctioning can stimulate the epiglottis, triggering a spasm and further obstructing the airway. Intubation is the primary intervention to secure the airway safely.

Choice D rationale:

Obtaining a throat culture is not the immediate action in suspected epiglottitis. While a throat culture may confirm the diagnosis, the priority is securing the airway to prevent respiratory distress and hypoxia.

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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?

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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?