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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Increase in serum sodium: Desmopressin, a synthetic form of vasopressin, works to decrease urine output and increase water reabsorption in the kidneys. Therefore, a therapeutic response to desmopressin would not result in an increase in serum sodium; rather, it would aim to normalize serum sodium levels by reducing excessive urine output.
B. Decrease in urine output: The primary therapeutic goal of desmopressin in the treatment of diabetes insipidus is to decrease urine output by increasing water reabsorption in the kidneys. Therefore, a decrease in urine output would indicate a positive response to the medication.
C. Increase in heart rate: Desmopressin primarily affects kidney function by increasing water reabsorption and does not typically have a direct effect on heart rate. Therefore, an increase in heart rate would not be a manifestation of a therapeutic response to desmopressin.
D. Decrease in blood pressure: Desmopressin works to increase water reabsorption in the kidneys and does not typically cause significant changes in blood pressure. Therefore, a decrease in blood pressure would not be a manifestation of a therapeutic response to desmopressin.
Correct Answer is C
Explanation
A. "You will be weighed twice a week while receiving TPN": While weight monitoring may be part of the client's overall care plan, it is not specifically related to TPN administration.
Therefore, this statement is not a priority for inclusion in the teaching.
B. "Your blood sugar will be checked once a day": Blood sugar monitoring may be necessary for clients receiving TPN, especially if they have diabetes or are at risk of hyperglycemia. However, the frequency of monitoring may vary depending on individual factors and is not universally applicable. Therefore, this statement may or may not be accurate for this client and should not be included in the teaching.
C. "You will have a central line placed to receive TPN": TPN solutions are administered through a central venous catheter to ensure adequate and safe delivery of nutrients directly into the bloodstream. Therefore, informing the client about the need for a central line is essential for TPN administration and should be included in the teaching.
D. "Your intake and output will be measured every 2 days": While monitoring intake and output is important for assessing fluid balance and renal function, the frequency of measurement may vary depending on the client's condition and institutional protocols. Therefore, this statement
may or may not be accurate for this client and should not be a priority for inclusion in the teaching.
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