A nurse is caring for a client who ingested a toxic amount of acetaminophen 36 hr ago.
Which of the following findings should the nurse monitor? Select all that apply.

Choice A rationale

Blood glucose monitoring accuracy is generally not directly affected by hydrochlorothiazide. The medication's impact is on glucose metabolism itself, not the accuracy of the measurement device. Hydrochlorothiazide affects the pancreatic beta cells or peripheral insulin sensitivity, leading to altered glucose homeostasis, not erroneous readings from a glucometer.

Choice B rationale

Decreasing insulin dosage is generally not appropriate when taking hydrochlorothiazide. Hydrochlorothiazide, a thiazide diuretic, can induce hyperglycemia by impairing insulin secretion from the pancreatic beta cells or by reducing peripheral glucose utilization, thereby requiring an *increase* in insulin dosage to maintain glycemic control, not a decrease.

Choice C rationale

Hydrochlorothiazide therapy can elevate blood glucose levels in clients who have diabetes. This effect is attributed to the medication's ability to impair insulin secretion from pancreatic beta cells or to decrease peripheral glucose utilization, leading to insulin resistance. This necessitates careful blood glucose monitoring (normal fasting glucose <100 mg/dL).

Choice D rationale

Reducing sodium in the diet while taking hydrochlorothiazide is beneficial for blood pressure control by augmenting the diuretic's effects, but it does not directly control blood glucose levels. While a healthy diet supports overall health, the primary mechanism of glucose elevation from hydrochlorothiazide is metabolic, not sodium-related.

Choice A rationale

Administering aspirin for fever in a client receiving alteplase is contraindicated. Alteplase is a potent thrombolytic, and aspirin, an antiplatelet agent, would significantly increase the risk of bleeding. If fever is present, acetaminophen would be the preferred antipyretic due to its lack of antiplatelet activity, minimizing the risk of hemorrhage in this high-risk patient.

Choice B rationale

Ambulation is contraindicated in a client receiving thrombolytic therapy. Alteplase lyses existing clots, increasing the risk of bleeding, especially from sites of trauma or increased pressure. Maintaining bed rest and limiting movement helps to minimize the risk of hemorrhagic complications, such as hematoma formation or internal bleeding, which could be exacerbated by physical activity.

Choice C rationale

Administering a sodium phosphate enema is contraindicated in a client receiving thrombolytic therapy. Sodium phosphate enemas can cause rectal irritation, mucosal injury, and increased peristalsis, all of which elevate the risk of gastrointestinal bleeding in a patient whose coagulation cascade is already significantly impaired by alteplase. Stool softeners are preferred if constipation is present.

Choice D rationale

Monitoring for changes in the level of consciousness is a critical intervention for a client receiving alteplase. Intracranial hemorrhage is the most serious and life-threatening complication of thrombolytic therapy. Any alterations in neurological status, such as confusion, disorientation, or decreased responsiveness, could indicate intracranial bleeding and necessitate immediate intervention and discontinuation of the infusion.