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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Increase the risk for bleeding: Herbal supplements like green tea, ginkgo, feverfew, garlic, and ginger can potentiate the effects of warfarin by enhancing its anticoagulant properties. This increases the risk of bleeding, as warfarin itself is a blood thinner designed to prevent clot formation. These herbs can further inhibit platelet aggregation or enhance anticoagulation, leading to a higher risk of bleeding complications.

B. Cause severe headache: While some herbal supplements can cause headaches as a side effect, this is not the primary concern when combined with warfarin. The interaction between these herbs and warfarin does not commonly result in severe headaches. The primary issue is the increased risk of bleeding.

C. Decrease the effects of the warfarin (Coumadin): These particular herbal supplements do not generally decrease the effects of warfarin. In fact, they are more likely to increase its anticoagulant effects. Some other substances might interfere with warfarin's efficacy, but the herbs listed are known to enhance its bleeding risk.

D. Cause severe hypotension: Severe hypotension is not a common result of combining these herbal supplements with warfarin. The primary interaction is related to the blood-thinning effects, not to blood pressure regulation. Herbal supplements that might affect blood pressure are not typically those that interact significantly with warfarin in this manner.

A. Easy bruising indicates the medication is effective. B. Inject the medication deep into the thigh muscle. C. Expect stools to become black and tarry. D. Use a soft bristle toothbrush.

Correct Answer is D

Explanation

A. Easy bruising indicates the medication is effective: While some bruising is possible, excessive bruising doesn't necessarily mean the medication is working effectively. It could indicate excessive anticoagulation, requiring dose adjustments.

B. Inject the medication deep into the thigh muscle: Heparin is injected subcutaneously, targeting the fatty tissue layer just beneath the skin. Injecting into the muscle can be painful and decrease absorption.

C. Expect stools to become black and tarry: Black stools can be a sign of upper gastrointestinal bleeding, a potential but uncommon side effect. The nurse should instruct the client to report any black stools but not expect them as a normal occurrence.

D. Use a soft bristle toothbrush: This is important because heparin increases bleeding risk, and a soft-bristled toothbrush minimizes gum irritation and potential bleeding.

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A patient is receiving alteplase (Activase), a thrombolytic drug. The nurse monitors the patient for which of the following possible adverse effects?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client taking warfarin (Coumadin) should be instructed to avoid herbal supplements such as green tea, ginkgo, feverfew, garlic, and ginger because these could:

Correct Answer is A

Explanation

A nurse is reinforcing teaching with a client who is to start subcutaneous heparin. Which of the following information should the nurse include in the teaching?

Correct Answer is D

Explanation

When asked if there are any regulatory controls on herbal or dietary supplements, the nurse responds to the client by informing him that herbal and dietary supplements are regulated by the:

What is the primary advantage of using low molecular weight heparins (LMWHs) over heparin?

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The nurse responds to the client's questions about CAM therapies and explains that some have been popular for centuries in treating conditions of the body and mind including which of the following? (Select All that Apply.)

Which of the following is administered to increase the number of circulating red blood cells?

Which of the following statements would most likely NOT be allowed on the label of a dietary supplement?