A nurse is caring for a client who received alteplase 12 hr ago following a thrombotic stroke. The nurse should monitor the client for which of the following adverse effects?

Laryngospasm

Polycythemia

Hemorrhage

Steatorrhea

Answer and Explanation

The Correct Answer is C

A.   Laryngospasm: Laryngospasm is not a commonly associated adverse effect of alteplase administration. It is more commonly associated with airway irritants or allergic reactions.
B.   Polycythemia: Polycythemia, or an abnormally high red blood cell count, is not a typical adverse effect of alteplase administration. Alteplase is a thrombolytic agent used to dissolve blood clots and is not associated with increasing red blood cell production.

C.   Hemorrhage: Hemorrhage, or bleeding, is the most significant adverse effect associated with alteplase administration. Alteplase works by promoting fibrinolysis and can increase the risk of bleeding, including intracranial hemorrhage, particularly in the context of thrombolytic therapy for stroke.
D.   Steatorrhea: Steatorrhea, or fatty stools, is not a commonly associated adverse effect of alteplase administration. It is more commonly associated with malabsorption disorders or pancreatic insufficiency.

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Correct Answer is B

Explanation

A. Hyperactive bowel sounds: Muscarinic agonist poisoning typically results in increased gastrointestinal motility and hyperactive bowel sounds. Atropine, an anticholinergic medication, works by blocking muscarinic receptors and reducing gastrointestinal motility. Therefore, the presence of hyperactive bowel sounds may indicate ongoing muscarinic stimulation and inadequate treatment with atropine.
B. Heart rate 90/min: Atropine is an anticholinergic medication that increases heart rate by blocking the parasympathetic effects of acetylcholine on the heart. Bradycardia is a common manifestation of muscarinic agonist poisoning, and an increase in heart rate following atropine administration indicates reversal of this effect and effective treatment.
C. Blood pressure 90/50 mm Hg: Atropine administration may result in transient hypertension due to its effect on increasing heart rate and cardiac output. Hypotension is a common
manifestation of muscarinic agonist poisoning, and an increase in blood pressure following atropine administration may indicate improvement in cardiovascular function. Therefore, a blood pressure of 90/50 mm Hg may not necessarily indicate effective treatment with atropine.
D. Increased salivation: Muscarinic agonist poisoning typically results in excessive salivation (sialorrhea) due to stimulation of muscarinic receptors in the salivary glands. Atropine administration works by blocking these muscarinic receptors and reducing salivation. Therefore, increased salivation would indicate ongoing muscarinic stimulation and inadequate treatment with atropine.

A. “I will consume foods that are soft or semisolid." B. "I will avoid consuming alcoholic beverages." C. “I will perform oral hygiene using a firm-bristle toothbrush." D. “I will rinse my mouth with saline every 2 hours while awake" E. None F. None

Correct Answer is B

Explanation

A. “I will consume foods that are soft or semisolid." While soft or semisolid foods may be easier to eat if the gums are sore, dietary modifications are not the primary focus of gingivitis management. Proper oral hygiene and avoiding irritants are more crucial. B. "I will avoid consuming alcoholic beverages." Alcohol can contribute to oral irritation, dry mouth, and worsening gingivitis. Avoiding alcohol helps reduce gum inflammation and promotes healing. C. “I will perform oral hygiene using a firm-bristle toothbrush." A firm-bristle toothbrush can cause gum irritation and worsen gingival inflammation. A soft-bristle toothbrush is recommended to clean the teeth effectively while protecting the gums. D. “I will rinse my mouth with saline every 2 hours while awake." Although saline rinses can help with minor oral irritation, frequent rinsing is not necessary for gingivitis. Instead, proper brushing, flossing, and using an antimicrobial mouthwash are more effective in managing the condition.

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A nurse is caring for a client who received alteplase 12 hr ago following a thrombotic stroke. The nurse should monitor the client for which of the following adverse effects?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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