The nurse is continuing to care for the client.

Exhibits

The nurse is initiating the client's plan of care.

Which of the following interventions should the nurse plan to implement? Select all that apply.

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.

Choice A rationale:

Taking temperature within 30 minutes after the first morning void is specific to ovulation prediction kits, not the basal body temperature method.

Choice B rationale:

Taking temperature 1 hour after getting out of bed is not accurate for tracking basal body temperature fluctuations related to the menstrual cycle.

Choice C rationale:

Taking temperature every night before going to bed does not provide consistent basal body temperature readings, as the body temperature needs to be taken at the same time every morning to detect subtle changes related to the menstrual cycle.

Choice D rationale:

This is the correct answer. To use the basal body temperature method effectively, the client should take their temperature immediately after waking and before getting out of bed every morning. This helps in detecting the slight rise in basal body temperature that occurs after ovulation, indicating the fertile period.