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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Free Nursing Study Resources

Correct Answer is A

Explanation

A. The correct order is

wipe off tops of insulin vials with alcohol sponge.
draw back amount of air into the syringe that equals total dose.
inject air equal to NPH dose into NPH vial. ...
air equal to regular dose into regular vial.
invert regular insulin bottle and withdraw regular insulin dose.
without adding more air into NPH vial, carefully withdraw NPH dose

B. Withdraw the regular insulin from the vial: This step should occur after injecting air into the regular insulin vial. The nurse should draw up the regular insulin before drawing up the NPH
insulin.

C. Inject air into the regular insulin vial: Inject air into the regular insulin vial is not thecorrect first step to avoid contamination of the clear insulin with cloudy insulin..
D. Withdraw the NPH insulin from the vial: This step should occur after withdrawing the regular insulin. The nurse should draw up the NPH insulin after drawing up the regular insulin to ensure the correct sequence and dosage.

A. File a report with the facility to document the incident as a near miss medication error. B. Contact the client's prescribing provider to report a facility medication error. C. Write in the client's medical record that the nurse prevented a facility medication error. D. Inform the client that medication will not be given due to a dispensary medication error.

Correct Answer is A

Explanation

A. Filing a report with the facility to document the incident as a near miss medication error is essential for tracking and investigating medication errors to prevent future occurrences.
B. While contacting the prescribing provider may be necessary, the priority is to report the error internally within the facility.
C. While documenting the nurse's actions is important, it is essential to report the error through the appropriate channels within the facility.
D. While informing the client about the error is necessary, the immediate action should be to report the error internally within the facility.

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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

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