A nurse is monitoring a client who is receiving alteplase (Activase) for a pulmonary embolism.

Which of the following findings requires immediate intervention by the nurse?

Hematuria.

Hematuria is the presence of blood in the urine and it indicates a bleeding complication from alteplase therapy.Alteplase is a thrombolytic drug that dissolves blood clots and restores blood flow, but it can also cause significant bleeding.

Hematuria requires immediate intervention by the nurse to stop the infusion and treat the bleeding.

Choice A is wrong because a blood pressure of 150/90 mmHg is not a contraindication for alteplase therapy.Alteplase should not be given to patients with severe uncontrolled hypertension, defined as systolic blood pressure >180 mmHg or diastolic blood pressure >110 mmHg.

Choice B is wrong because a heart rate of 100/min is not a sign of adverse reaction to alteplase therapy.Alteplase can cause cardiac arrhythmias, but they are usually transient and do not require treatment.

Choice C is wrong because a hemoglobin of 12 g/dL is within the normal range for adults (13.5-17.5 g/dL for males and 12-15.5 g/dL for females).

A low hemoglobin level may indicate bleeding or hemolysis from alteplase therapy and should be monitored closely.

Pinch the skin at the injection site.

This is because enoxaparin is a low molecular weight heparin that is administered subcutaneously, which means under the skin.Pinching the skin helps to create a fold of tissue that can be injected with the medication.Expelling the air bubble from the prefilled syringe is not necessary, as it helps to prevent leakage of the medication after injection.Injecting the medication into the deltoid muscle is wrong, as enoxaparin should not be given intramuscularly.Applying pressure to the injection site after administration is also wrong, as it can cause bruising or hematoma.