A nurse is preparing to administer vancomycin IV to an adult client.

The client asks the nurse if the medication can be given 2 hr earlier.

Which of the following statements should the nurse make?

“I can adjust the time and schedule for when it’s convenient for you.”.

“I can start the medication 30 minutes earlier.”.

“I have up to 2 hours after the usual schedule time to give you this medication.”.

“I can infuse the medication at a faster rate.”.

None

Answer and Explanation

The Correct Answer is B

The correct answer is choice b. "I can start the medication 30 minutes earlier."Choice A rationale: This is an inappropriate response, as the nurse should not adjust the time and schedule for the administration of alteplase recombinant, which is a time-sensitive medication used to treat a thrombus in the coronary artery. The administration of this medication must be done within a specific time frame to be effective.Choice B rationale: This is the correct answer. Alteplase recombinant is a thrombolytic medication used to dissolve blood clots in the coronary artery. It is a time-sensitive medication, and it is crucial to administer it as soon as possible to minimize the damage to the heart muscle. Starting the medication 30 minutes earlier is an appropriate action to include in the plan of care, as it can help ensure the medication is administered within the recommended time frame.Choice C rationale: This is an inappropriate response. Alteplase recombinant should be administered within a specific time frame, typically within 3 to 4.5 hours of the onset of symptoms. Waiting up to 2 hours after the usual schedule time to give the medication would be outside the recommended time frame and could potentially reduce the effectiveness of the treatment.Choice D rationale: This is an inappropriate response. Alteplase recombinant should be infused at a specific rate, as recommended by the manufacturer or healthcare provider. Infusing the medication at a faster rate could increase the risk of adverse effects and should not be included in the plan of care without specific instructions from the healthcare provider.

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Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"C"}

Explanation

The nurse should first administer oxygen at 2 L/min via nasal cannula because the client has signs of hypoxemia (low oxygen saturation) and respiratory distress (increased respiratory rate) that may worsen the chest pain and myocardial ischemia. Oxygen therapy can help improve oxygen delivery to the heart muscle and reduce the workload of the heart.
The nurse should then administer sublingual nitroglycerin as prescribed because nitroglycerin is a vasodilator that can help relieve chest pain by dilating the coronary arteries and improving blood flow to the heart. Nitroglycerin can also lower blood pressure and reduce cardiac preload and afterload, which can decrease myocardial oxygen demand.
Other choices:

• Prepare the client for cardiac catheterization: This may be a later intervention if the chest pain persists or if the client has a confirmed myocardial infarction, but it is not the first priority for the nurse. Cardiac catheterization is an invasive procedure that involves inserting a catheter into a large artery and advancing it to the coronary arteries to visualize any blockages or stenosis. The procedure may also involve angioplasty or stent placement to restore blood flow to the affected area.

• Request a prescription for an increase in statin: This may be a long-term intervention to lower the client’s LDL cholesterol and prevent further plaque formation in the coronary arteries, but it is not an immediate intervention for chest pain. Statins are lipid-lowering drugs that can reduce the risk of cardiovascular events in clients with CAD, but they do not have a direct effect on chest pain or myocardial ischemia.

• Check a STAT cardiac troponin: This may be a diagnostic test to confirm or rule out a myocardial infarction, but it is not an intervention for chest pain. Cardiac troponin is a protein that is released into the bloodstream when there is damage to the heart muscle. Elevated levels of cardiac troponin indicate a myocardial infarction or other cardiac injury.

• Request a prescription for a beta-blocker: This may be an adjunctive therapy to reduce chest pain and prevent complications, but it is not the first-line intervention for chest pain. Beta-blockers are drugs that block the effects of adrenaline on the heart and blood vessels, which can lower heart rate, blood pressure, and myocardial oxygen demand. Beta-blockers can also prevent arrhythmias and reduce mortality in clients with CAD.

A. Family history of malignant hypertension. B. Hip arthroplasty 1 week ago. C. Chronic obstructive pulmonary disease. D. Acute renal failure 6 months ago.

Correct Answer is B

Explanation

The correct answer is B. Hip arthroplasty 1 week ago.

Alteplase is a drug that dissolves blood clots by converting plasminogen to plasmin. It can be used for acute ischemic stroke, but it has some contraindications that depend on the indication and the type of administration of the drug. Some common contraindications for alteplase are hypersensitivity, active internal bleeding, history of intracranial hemorrhage, bleeding disorders, and high blood pressure. Other contraindications may vary depending on the specific condition and the time window of treatment. Alteplase can cause serious or fatal bleeding as a side effect.

Choice A is wrong because family history of malignant hypertension is not an absolute contraindication for alteplase, although uncontrolled hypertension (>185 mmHg SBP or >110 mmHg DBP) is.

Choice C is wrong because chronic obstructive pulmonary disease is not a contraindication for alteplase, although it may increase the risk of pulmonary hemorrhage.

Choice D is wrong because acute renal failure 6 months ago is not a contraindication for alteplase, although current use of direct thrombin inhibitors or direct factor Xa inhibitors is.

Normal ranges for blood pressure are <120/80 mmHg for normal, 120-129/<80 mmHg for elevated, 130-139/80-89 mmHg for stage 1 hypertension, and ≥140/≥90 mmHg for stage 2 hypertension.

Normal ranges for platelet count are 150,000 to 450,000 platelets per microliter of blood.

Normal ranges for INR are 0.8 to 1.2 for people who are not taking blood thinners and 2 to 3 for people who are taking warfarin.

Normal ranges for aPTT are 25 to 35 seconds for people who are not taking blood thinners and 46 to 70 seconds for people who are taking heparin.

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A nurse is preparing to administer vancomycin IV to an adult client. The client asks the nurse if the medication can be given 2 hr earlier. Which of the following statements should the nurse make?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client. Exhibits Complete the following sentence by using the list of options. After notifying the provider, the nurse should first and then .

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"C"}

Explanation

A nurse in an emergency department is reviewing the medical record of a client who is having an acute myocardial infarction. Which of the following findings places the client at risk if he receives alteplase?

Correct Answer is B

Explanation

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A nurse is preparing to administer vancomycin IV to an adult client.

The client asks the nurse if the medication can be given 2 hr earlier.

Which of the following statements should the nurse make?