A patient is receiving alteplase (Activase), a thrombolytic drug. The nurse monitors the patient for which of the following possible adverse effects?
Temperature of 100.8 Degrees Fahrenheit (38.2 Degrees Celsius)
Skin rash with urticaria
Wheezing with labored breathing
Bruising and epistaxis
The Correct Answer is D
A. Temperature of 100.8 Degrees Fahrenheit (38.2 Degrees Celsius): Fever can indicate a potential adverse reaction to the medication or may be a sign of infection, which could complicate the patient's condition. While a fever can be a sign of an infection, it's not a typical adverse effect for alteplase
B. Skin rash with urticaria: Skin rash and urticaria (hives) can indicate an allergic reaction to alteplase. Allergic reactions can range from mild to severe and may necessitate discontinuation of the medication and administration of appropriate treatment, such as antihistamines or corticosteroids, depending on the severity of the reaction but it's less common than bleeding.
C. Wheezing with labored breathing: Wheezing and labored breathing can indicate a severe allergic reaction or anaphylaxis to alteplase but again, bleeding is a more prominent concern.
D. Bruising and epistaxis: Alteplase increases the risk of bleeding due to its thrombolytic activity. Bruising and epistaxis (nosebleeds) are common manifestations of bleeding associated with alteplase therapy. Monitoring for these signs helps detect potential bleeding complications early, allowing for prompt intervention to minimize further bleeding and manage the patient's condition appropriately.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C"]
Explanation
A. Constipation: Constipation is not a commonly reported adverse effect of clopidogrel (Plavix). Clopidogrel is an antiplatelet medication that works by inhibiting platelet aggregation, and gastrointestinal effects such as constipation are not typically associated with its use.
B. Bruising: This is a correct answer. Bruising is a known adverse effect of clopidogrel. As an antiplatelet medication, clopidogrel inhibits platelet aggregation, which can increase the risk of bleeding and bruising.
C. Rash: Rash is a potential adverse effect of clopidogrel, although it is not as common as other side effects such as bruising or gastrointestinal symptoms. Patients taking clopidogrel should be monitored for signs of allergic reactions, including rash, which may indicate the need for further evaluation or discontinuation of the medication.
D. Headache: Headache is not a commonly reported adverse effect of clopidogrel. While some patients may experience headache while taking clopidogrel, it is not considered a frequent or significant side effect of the medication.
E. Diarrhea: Diarrhea is not a commonly reported adverse effect of clopidogrel. Gastrointestinal symptoms such as diarrhea are not typically associated with clopidogrel use, although some patients may experience gastrointestinal upset as a side effect of antiplatelet therapy.
Correct Answer is A
Explanation
A. "This medication will not break down clots but will make it less likely that the clot will get larger." Warfarin (Coumadin) is an anticoagulant medication that works by inhibiting the synthesis of certain clotting factors in the liver. It does not directly break down existing clots but prevents the formation of new clots and the extension of existing ones. This response provides accurate information about the mechanism of action of warfarin.
B. "It will break down the clot within 8 to 12 hours of administration." This statement is incorrect. Warfarin does not have an immediate effect on existing clots. Its action is primarily preventive, reducing the risk of further clot formation and allowing the body's natural processes to gradually break down existing clots over time.
C. "It will take 7 to 10 days for the clot to break down." While the body's natural processes may start breaking down the clot within this timeframe, warfarin itself does not directly cause the dissolution of clots. This response is partially accurate in terms of the timeline for the body's natural clot resolution but does not specify that warfarin itself is not responsible for clot breakdown.
D. "You will need to be on this medication for a long time before it will break down the clot." This statement is misleading. Warfarin's role is to prevent the formation of new clots and further extension of existing ones rather than directly breaking down clots. Additionally, the duration of warfarin therapy is typically determined based on the individual's risk factors for clot formation, and it may not necessarily correlate with the time it takes for existing clots to resolve.
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