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 A

Explanation

A. This statement indicates correct understanding. Remaining upright after taking ferrous gluconate reduces the risk of esophageal irritation or discomfort, which can occur if the medication refluxes into the esophagus. This is an important teaching point for clients taking iron supplements.

B. This statement is incorrect. Antacids can interfere with the absorption of ferrous gluconate by altering stomach acidity, which is necessary for optimal iron absorption. Clients should avoid taking antacids within two hours of iron supplements.

C. This statement is incorrect. Milk and other calcium-containing products inhibit the absorption of iron. It is recommended to take ferrous gluconate with water or a source of vitamin C, such as orange juice, to enhance absorption.

D. This statement is incorrect. Black stools are a common and harmless side effect of taking iron supplements and do not typically require notifying the provider unless accompanied by other symptoms like abdominal pain or blood in the stool.

A. Have another nurse verify the medication for the secondary infusion. B. Flush the IV site with sterile water prior to connecting the secondary infusion. C. Hang the secondary infusion higher than the primary IV infusion. D. Disconnect the primary IV infusion to connect the secondary infusion. E. None F. None

Correct Answer is C

Explanation

A.While medication verification is important, this is not specific to administering an intermittent IV bolus. It is standard practice for high-alert medications, not routine antibiotics.

B. Flushing the IV site with sterile water prior to connecting the secondary infusion is not standard practice. Normal saline is typically used to maintain patency, but it is not necessary before connecting the secondary infusion.
C.To administer a secondary infusion (e.g., antibiotic), the secondary bag must be hung higher than the primary infusion. This allows gravity to prioritize the secondary infusion through the Y-site.

D. Disconnecting the primary IV infusion to connect the secondary infusion is not correct. The secondary infusion should connect to the primary line without disrupting the ongoing infusion unless otherwise indicated.

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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

A nurse is teaching a client who has a prescription for ferrous gluconate. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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