A nurse is monitoring a client who is receiving streptokinase, a first-generation thrombolytic agent, for a pulmonary embolism. The nurse observes that the client has developed a rash, fever, and hypotension after receiving the medication.

Which of the following actions should the nurse take first?

Stop the infusion of streptokinase

Administer epinephrine as ordered

Notify the health care provider

Draw blood samples for antibody testing.

Answer and Explanation

The Correct Answer is A

The client has developed signs of an allergic reaction to streptokinase, which can be life-threatening. Streptokinase is a drug that can cause bleeding, allergic reactions, and general discomfort. Allergic reactions can include nausea, vomiting, and low blood pressure. The first step in managing anaphylaxis is to remove the trigger if possible.

Therefore, stopping the infusion of streptokinase is the most appropriate action.

Choice B is wrong because administering epinephrine is not the first action to take. Epinephrine is a medication that can help reduce an allergic response by constricting blood vessels and relaxing airways.

However, it should be used after stopping the infusion of streptokinase and only if the client has an auto-injector or a doctor’s order.

Choice C is wrong because notifying the health care provider is not the first action to take.

The client needs immediate treatment to prevent shock and respiratory failure.

Calling 999 for an ambulance is more urgent than notifying the health care provider.

Choice D is wrong because drawing blood samples for antibody testing is not the first action to take.

Antibody testing can help diagnose a previous exposure to streptokinase, but it does not help.

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Correct Answer is ["A","B","D"]

Explanation

A. History of peptic ulcer disease: Peptic ulcers increase the risk of gastrointestinal bleeding, making thrombolytics dangerous for these clients.

B. Recent dental extraction: Any recent surgery, including dental procedures, can lead to excessive bleeding due to clot dissolution from thrombolytics.

C. Chronic atrial fibrillation: Atrial fibrillation increases the risk of thromboembolism, but it is not a contraindication for thrombolytics. Clients with AFib may already be on anticoagulation therapy, which requires monitoring, but thrombolytics are still used in certain cases (e.g., ischemic stroke).

D. Pregnancy:Pregnancy is a relative contraindication due to the risk of placental abruption, fetal loss, and severe maternal bleeding.

E. Diabetes mellitus:Diabetes itself does not increase the risk of bleeding, so it is not a contraindication. However, diabetic clients with complications (e.g., retinopathy) require careful assessment.

A. Check the client’s blood pressure and pulse B. Obtain a baseline complete blood count (CBC) and coagulation studies C. Assess the client’s neurological status using a standardized scale D. All of the above.

Correct Answer is D

Explanation

The nurse should take all of the following actions before administering alteplase, a second-generation thrombolytic agent, to a client with an acute ischemic stroke:

• Check the client’s blood pressure and pulse.Alteplase can cause bleeding and hypotension, so the nurse should monitor the client’s vital signs closely and report any abnormal findings to the provider.

• Obtain a baseline complete blood count (CBC) and coagulation studies.Alteplase can increase the risk of hemorrhage, so the nurse should check the client’s platelet count, hemoglobin, hematocrit, prothrombin time (PT), international normalized ratio (INR), and activated partial thromboplastin time (aPTT) before and during therapy.The normal ranges for these tests are as follows:

➤ Platelet count: 150,000–400,000/mm3

➤ Hemoglobin: 13.5–17.5 g/dL for males; 12.0–15.5 g/dL for females

➤ Hematocrit: 38.8–50.0% for males; 34.9–44.5% for females

➤ PT: 11–13.5 seconds

➤ INR: 0.8–1.1

➤ aPTT: 25–35 seconds

• Assess the client’s neurological status using a standardized scale.Alteplase can improve the neurological outcome of ischemic stroke by dissolving the clot and restoring blood flow to the brain.However, it can also cause intracranial hemorrhage, which can worsen the neurological deficit.Therefore, the nurse should use a scale such as the National Institutes of Health Stroke Scale (NIHSS) or the Glasgow Coma Scale (GCS) to evaluate the client’s level of consciousness, motor function, sensory function, speech, vision, and other neurological functions before and after administering alteplase.

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A nurse is monitoring a client who is receiving streptokinase, a first-generation thrombolytic agent, for a pulmonary embolism. The nurse observes that the client has developed a rash, fever, and hypotension after receiving the medication. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the contraindications for thrombolytic therapy for a client with a peripheral arterial occlusion. Which of the following conditions would make the client ineligible for this therapy? (Select all that apply.)

Correct Answer is ["A","B","D"]

Explanation

A nurse is preparing to administer alteplase, a second-generation thrombolytic agent, to a client with an acute ischemic stroke. Which of the following actions should the nurse take before administering the medication?

Correct Answer is D

Explanation

A nurse is caring for a client who has received a thrombolytic agent for an acute ischemic stroke. The nurse notes that the client’s activated partial thromboplastin time (aPTT) is 120 seconds. What is the most appropriate action by the nurse?

A nurse is monitoring a client who is receiving streptokinase, a first-generation thrombolytic agent, for a pulmonary embolism. The nurse observes that the client has developed a rash, fever, and hypotension after receiving the medication. Which of the following actions should the nurse take first?

A nurse is reviewing the contraindications for thrombolytic therapy for a client with a peripheral arterial occlusion. Which of the following conditions would make the client ineligible for this therapy? (Select all that apply.)