A nurse is caring for a client who has received a thrombolytic agent for an acute ischemic stroke. The nurse notes that the client’s activated partial thromboplastin time (aPTT) is 120 seconds. What is the most appropriate action by the nurse?

Document the finding as normal

Administer vitamin K as ordered

Prepare to give protamine sulfate

Notify the health care provider.

Answer and Explanation

The Correct Answer is D

The nurse should notify the health care provider because an activated partial thromboplastin time (aPTT) of 120 seconds is significantly elevated and indicates a high risk of bleeding. The normal range for aPTT is 25 to 35 seconds. A thrombolytic agent is a medication that dissolves blood clots and restores blood flow to the brain after an acute ischemic stroke. However, it can also cause excessive bleeding and hemorrhage, which can be life-threatening.

Choice A is wrong because the finding is not normal and requires immediate intervention.

Choice B is wrong because vitamin K is an antidote for warfarin, an oral anticoagulant, not for a thrombolytic agent.

Vitamin K would not reverse the effects of a thrombolytic agent.

Choice C is wrong because protamine sulfate is an antidote for heparin, an injectable anticoagulant, not for a thrombolytic agent.

Protamine sulfate would not reverse the effects of a thrombolytic agent.

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Correct Answer is ["A","B","D"]

Explanation

A. History of peptic ulcer disease: Peptic ulcers increase the risk of gastrointestinal bleeding, making thrombolytics dangerous for these clients.

B. Recent dental extraction: Any recent surgery, including dental procedures, can lead to excessive bleeding due to clot dissolution from thrombolytics.

C. Chronic atrial fibrillation: Atrial fibrillation increases the risk of thromboembolism, but it is not a contraindication for thrombolytics. Clients with AFib may already be on anticoagulation therapy, which requires monitoring, but thrombolytics are still used in certain cases (e.g., ischemic stroke).

D. Pregnancy:Pregnancy is a relative contraindication due to the risk of placental abruption, fetal loss, and severe maternal bleeding.

E. Diabetes mellitus:Diabetes itself does not increase the risk of bleeding, so it is not a contraindication. However, diabetic clients with complications (e.g., retinopathy) require careful assessment.

A. Stop the infusion of streptokinase B. Administer epinephrine as ordered C. Notify the health care provider D. Draw blood samples for antibody testing.

Correct Answer is A

Explanation

The client has developed signs of an allergic reaction to streptokinase, which can be life-threatening.Streptokinase is a drug that can cause bleeding, allergic reactions, and general discomfort.Allergic reactions can include nausea, vomiting, and low blood pressure.The first step in managing anaphylaxis is to remove the trigger if possible.

Therefore, stopping the infusion of streptokinase is the most appropriate action.

Choice B is wrong because administering epinephrine is not the first action to take.Epinephrine is a medication that can help reduce an allergic response by constricting blood vessels and relaxing airways.

However, it should be used after stopping the infusion of streptokinase and only if the client has an auto-injector or a doctor’s order.

Choice C is wrong because notifying the health care provider is not the first action to take.

The client needs immediate treatment to prevent shock and respiratory failure.

Calling 999 for an ambulance is more urgent than notifying the health care provider.

Choice D is wrong because drawing blood samples for antibody testing is not the first action to take.

Antibody testing can help diagnose a previous exposure to streptokinase, but it does not help.

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A nurse is caring for a client who has received a thrombolytic agent for an acute ischemic stroke. The nurse notes that the client’s activated partial thromboplastin time (aPTT) is 120 seconds. What is the most appropriate action by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the contraindications for thrombolytic therapy for a client with a peripheral arterial occlusion. Which of the following conditions would make the client ineligible for this therapy? (Select all that apply.)

Correct Answer is ["A","B","D"]

Explanation

A nurse is monitoring a client who is receiving streptokinase, a first-generation thrombolytic agent, for a pulmonary embolism. The nurse observes that the client has developed a rash, fever, and hypotension after receiving the medication. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

A nurse is reviewing the contraindications for thrombolytic therapy for a client with a peripheral arterial occlusion. Which of the following conditions would make the client ineligible for this therapy? (Select all that apply.)

A nurse is caring for a client who has received a thrombolytic agent for an acute ischemic stroke. The nurse notes that the client’s activated partial thromboplastin time (aPTT) is 120 seconds. What is the most appropriate action by the nurse?

A nurse is preparing to administer alteplase, a second-generation thrombolytic agent, to a client with an acute ischemic stroke. Which of the following actions should the nurse take before administering the medication?