A nurse in the emergency department is planning care for a client who had a myocardial infarction and is receiving thrombolytic therapy with an WV infusion of alteplase. Which of the following interventions should the nurse include in the plan?

Administer aspirin instead of acetaminophen for fever

Ambulate the client as often as tolerated

Administer a sodium phosphate enema for constipation

Monitor for changes in level of consciousness

Answer and Explanation

The Correct Answer is D

When planning care for a client who had a myocardial infarction and is receiving thrombolytic therapy with an IV infusion of alteplase, the nurse should include the intervention of monitoring for changes in the client's level of consciousness.

Alteplase is a thrombolytic medication used to break down blood clots in certain medical emergencies, such as acute myocardial infarction (heart attack) or ischemic stroke. One of the potential complications of thrombolytic therapy, including alteplase, is bleeding. The medication's action of breaking down blood clots can also affect the body's natural clotting mechanisms, increasing the risk of bleeding.

Bleeding in the brain is a severe and potentially life-threatening complication associated with thrombolytic therapy. Therefore, it is essential for the nurse to closely monitor the client for any signs of intracranial bleeding, such as changes in the level of consciousness, confusion, severe headache, slurred speech, or weakness on one side of the body.

Let's go through the other options:

A. Administer aspirin instead of acetaminophen for fever: While aspirin is commonly used in the management of myocardial infarction, it is not specifically indicated for fever. Acetaminophen is the preferred antipyretic medication for fever management in most cases, and it does not interfere with the action of thrombolytic therapy.

B. Ambulate the client as often as tolerated: While early ambulation is beneficial for clients with myocardial infarction, it may not be appropriate during thrombolytic therapy. Thrombolytic therapy carries an increased risk of bleeding, and ambulation may be limited or contraindicated during the treatment period, depending on the client's overall condition and bleeding risk.

C. Administer a sodium phosphate enema for constipation: The administration of a sodium phosphate enema is not a specific intervention related to thrombolytic therapy or myocardial infarction. Bowel management is important for client comfort and overall well-being, but it is not a priority intervention in the immediate care of a client undergoing thrombolytic therapy.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Furosemide is a loop diuretic commonly used to treat fluid volume excess by promoting diuresis. One of the expected outcomes of furosemide administration is an increased urinary output as excess fluid is eliminated from the body. Therefore, if the medication has been effective, the nurse would expect to see an increased urinary output as a result of the diuretic effect.

Increased respiratory rate (B) is not an expected outcome of furosemide administration. It may occur in some cases due to increased fluid elimination and potential electrolyte imbalances, but it is not the primary indicator of the medication's effectiveness.

Decreased blood pressure (C) is a possible outcome of furosemide administration due to the diuretic effect and subsequent reduction in fluid volume. However, it is not the most specific indicator of the medication's effectiveness in this case.

Increased pulse (D) is not a typical finding associated with the effectiveness of furosemide. In fact, furosemide can sometimes cause a decrease in heart rate due to its impact on fluid and electrolyte balance.

A. The client has a history of alcohol use disorder but is currently sober B. The client recently had a norovirus infection C. The client smokes one pack of cigarette per day D. The client has a history of rheumatoid arthritis

Correct Answer is C

Explanation

Smoking is a known risk factor for the development of aspirin-induced ulcers. It can increase the risk of gastrointestinal bleeding and compromise the integrity of the gastric mucosa. Smoking can also impair the healing process and increase the risk of complications associated with ulcers.

While the other factors mentioned in the options may have their own health implications, smoking is specifically associated with an increased risk of aspirin-induced ulcers. Therefore, the nurse should identify the client's smoking habit as a risk factor for the development of an aspirin-induced ulcer.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse in the emergency department is planning care for a client who had a myocardial infarction and is receiving thrombolytic therapy with an WV infusion of alteplase. Which of the following interventions should the nurse include in the plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has fluid volume excess and received furosemide 40 mg via intermittent IV bolus 1 hr ago. Which of the following findings indicates that the medication has been effective?

Correct Answer is A

Explanation

A nurse is caring for a client who is starting to take aspirin 81 mg daily. Which of the following findings should the nurse identify as a risk factor for the client's development of an aspirin-induced ulcer?

Correct Answer is C

Explanation

A nurse is preparing to administer morphine 8 mg IV intermittent bolus to a client. The amount available is morphine 10 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

A nurse is caring for a client who has anxiety and a prescription for oral lorazepam PRN. Which of the following is the correct way to transcribe the prescription into the electronic medical record?

A nurse is providing discharge teaching to a client who has a prescription for enoxaparin. Which of the following instructions should the nurse include in the teaching?

A nurse is caring for a client who has a new prescription for metformin. Which of the following laboratory results should the nurse evaluate prior to administering the first dose?

A nurse is assessing a client who is receiving total parenteral nutrition (TPN). Which of the following findings should the nurse identify as an adverse effect of TPN

A nurse is reviewing the laboratory results of a client who has been taking warfarin for 3 months. Which of the following laboratory results Indicates that the medication has been effective?

A nurse is providing teaching for a client who has a new prescription for rifampin. Which of the following statements should the nurse include?