A nurse is planning care for a client who is to receive alteplase recombinant for a thrombus in the coronary artery.
Which of the following actions should the nurse include in the plan of care?

Observe for bruising of the skin.

Administer medications intramuscularly.

Monitor vital signs every 4 hours

Provide a diet low in protein.

Answer and Explanation

The Correct Answer is A

The correct answer is **a. Observe for bruising of the skin.**

Choice A rationale: Observing for bruising of the skin is an appropriate nursing intervention when caring for a client receiving alteplase (recombinant tissue plasminogen activator or rt-PA), a thrombolytic medication used to dissolve blood clots. Alteplase can increase the risk of bleeding, including bruising, as it works to break down the clot. Closely monitoring the client for any signs of bleeding or bruising is crucial to identify and manage potential complications.

Choice B rationale: Administering medications intramuscularly is not recommended when a client is receiving alteplase. Intramuscular injections can increase the risk of bleeding and should be avoided, as alteplase can impair the body's ability to form clots and stop bleeding.

Choice C rationale: Monitoring vital signs every 4 hours is not the appropriate frequency for a client receiving alteplase. Vital signs should be monitored more frequently, typically every 30 minutes to 1 hour, to closely observe for any changes that may indicate bleeding or other complications.

Choice D rationale: Providing a diet low in protein is not a necessary intervention for a client receiving alteplase. Alteplase works by targeting the blood clot and does not require specific dietary modifications. The focus should be on monitoring for bleeding and managing any potential complications, rather than adjusting the client's diet.

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Correct Answer is C

Explanation

Choice A rationale:

Administering 2 ounces of water to the newborn prior to the test is not a standard practice for newborn genetic screening. Newborns are typically screened for genetic disorders through a blood test, not by giving them water.

Choice B rationale:

This statement is incorrect. Newborn genetic screening is usually performed shortly after birth, not at 2 months old. Early screening allows for the early detection of certain genetic disorders, enabling timely interventions if needed.

Choice D rationale:

Drawing blood from the newborn's inner elbow is not specific guidance related to newborn genetic screening. Blood can be drawn from various sites, and healthcare providers choose the most appropriate site based on the newborn's condition and the required tests.

A. A nurse expresses concern that another shift works fewer holiday hours. B. A nurse has a personal difficulty with caring for clients who have HIV. C. A nurse experiences insulting comments directed at them by another nurse. D. A nurse submits a complaint about another department's handoff reporting.

Correct Answer is C

Explanation

Choice A rationale:

Expressing concern about another shift's holiday hours does not necessarily involve interpersonal conflict. It may reflect dissatisfaction but doesn't involve direct conflict between individuals.

Choice B rationale:

A personal difficulty with caring for clients who have HIV could be a challenge for the nurse, but it's not an example of interpersonal conflict. It represents a personal struggle rather than a conflict with another individual.

Choice C rationale:

Insulting comments directed at a nurse by another nurse represent interpersonal conflict. Such behavior involves a direct clash of personalities and can create a hostile work environment, affecting the nurse's well-being and job performance. Addressing this type of conflict is crucial for maintaining a positive work atmosphere.

Choice D rationale:

Submitting a complaint about another department's handoff reporting might indicate dissatisfaction or concerns about workflow, but it's not necessarily an interpersonal conflict. It could be a communication issue or a difference in professional opinion rather than a direct clash between individuals.

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A nurse is planning care for a client who is to receive alteplase recombinant for a thrombus in the coronary artery. Which of the following actions should the nurse include in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to the parents of a newborn about newborn genetic screening.Which of the following statements should the nurse include in the teaching?

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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A nurse is planning care for a client who is to receive alteplase recombinant for a thrombus in the coronary artery.
Which of the following actions should the nurse include in the plan of care?