A patient is receiving alteplase (Activase), a thrombolytic drug. The nurse monitors the patient for which of the following possible adverse effects?
Temperature of 100.8 Degrees Fahrenheit (38.2 Degrees Celsius)
Skin rash with urticaria
Wheezing with labored breathing
Bruising and epistaxis
The Correct Answer is D
A. Temperature of 100.8 Degrees Fahrenheit (38.2 Degrees Celsius): Fever can indicate a potential adverse reaction to the medication or may be a sign of infection, which could complicate the patient's condition. While a fever can be a sign of an infection, it's not a typical adverse effect for alteplase
B. Skin rash with urticaria: Skin rash and urticaria (hives) can indicate an allergic reaction to alteplase. Allergic reactions can range from mild to severe and may necessitate discontinuation of the medication and administration of appropriate treatment, such as antihistamines or corticosteroids, depending on the severity of the reaction but it's less common than bleeding.
C. Wheezing with labored breathing: Wheezing and labored breathing can indicate a severe allergic reaction or anaphylaxis to alteplase but again, bleeding is a more prominent concern.
D. Bruising and epistaxis: Alteplase increases the risk of bleeding due to its thrombolytic activity. Bruising and epistaxis (nosebleeds) are common manifestations of bleeding associated with alteplase therapy. Monitoring for these signs helps detect potential bleeding complications early, allowing for prompt intervention to minimize further bleeding and manage the patient's condition appropriately.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Black Cohosh: This herb is more commonly used for menopausal symptoms and not typically associated with immune system benefits.
B. Gingko: Gingko is primarily studied for its potential benefits on memory and cognitive function, not necessarily the immune system.
C. Kava Kava: Kava kava is known for its calming effects and used for anxiety relief, not immune system support.
D. Echinacea: This herb has been widely studied and used for centuries for its potential immune-boosting properties. While research results are somewhat mixed, it's one of the most popular herbs associated with immune support.
Correct Answer is D
Explanation
A. Clotting at the incision site. Enoxaparin (Lovenox) is an anticoagulant medication used to prevent blood clots, particularly deep vein thrombosis (DVT) and pulmonary embolism (PE), which are common complications following orthopedic surgeries like knee replacement. Monitoring for clotting at the incision site is essential to ensure that the medication is effectively preventing excessive clot formation while also ensuring that the patient does not experience excessive bleeding.
B. Increased pain. While increased pain could be a concern postoperatively, particularly after a surgical procedure like knee replacement, it is not a specific monitoring parameter for enoxaparin administration. Pain management is typically addressed separately, and increased pain may indicate issues such as inadequate analgesia, surgical complications, or other factors unrelated to enoxaparin therapy.
C. Gingival hyperplasia. Gingival hyperplasia refers to an overgrowth of gum tissue and is not directly associated with enoxaparin therapy. This side effect is more commonly associated with certain medications such as phenytoin and cyclosporine rather than anticoagulants like enoxaparin. Monitoring for gingival hyperplasia would not be relevant in this context.
D. Signs and symptoms of bruising and bleeding. This is the correct answer. Enoxaparin is an anticoagulant medication, which increases the risk of bleeding. Therefore, monitoring for signs and symptoms of bruising and bleeding is crucial to detect any potential complications such as hemorrhage or hematoma formation. This includes assessing for unusual bruising, bleeding from the gums, nosebleeds, hematuria, melena, or any other signs of internal or external bleeding. Prompt recognition and management of bleeding complications are essential to ensure patient safety during enoxaparin therapy, especially following orthopedic surgery.
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