A patient is receiving thrombolytic therapy, and the nurse monitors the patient for adverse effects. What is the most common undesirable effect of thrombolytic therapy?

Anaphylactic reactions

Nausea and vomiting

Internal and superficial bleeding

Dysrhythmias

Answer and Explanation

The Correct Answer is C

A. Anaphylactic reactions: Rare with thrombolytics.
B. Nausea and vomiting: These may occur but are not the most common or most clinically significant adverse effects.
C. Internal and superficial bleeding: The most common and clinically important adverse effect of thrombolytic therapy is bleeding (both superficial and internal). Monitor for bleeding and hemorrhagic complications.
D. Dysrhythmias: Cardiac dysrhythmias can occur, especially after reperfusion, but bleeding is the primary and most common risk.

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Correct Answer is D

Explanation

A. 12 hours: that would reflect long-acting insulin duration, not the short/regular insulin peak.
B. 1/2 hour: ~30 minutes is the onsetof regular insulin, not the peak; hypoglycemia risk is greater at peak.
C. 8 hours: that’s longer than the typical peak/duration for regular insulin (NPH peaks later).
D. 3 hours: regular (short-acting) insulin typically has a peak about 2–4 hours after injection, so teaching patients to be alert around ~3 hours after each regular insulin dose is appropriate.

A. Assess the patient for symptoms of hyperglycemia B. Administer a continuous infusion of 5% dextrose for 24 hours. C. Give the patient a snack of crackers and peanut butter. D. Have the patient drink a glass of orange juice or nonfat milk.

Correct Answer is D

Explanation

A. Assess the patient for symptoms of hyperglycemia: The immediate concern after glucagon is preventing recurrent hypoglycemia, not hyperglycemia.
B. Administer a continuous infusion of 5% dextrose for 24 hours: Usually not required if the patient can tolerate oral intake and glucose stabilizes.
C. Give the patient a snack of crackers and peanut butter: Reasonable, but solid snack may be harder to tolerate immediately after an episode -liquids are recommended first if swallowing is safe.
D. Have the patient drink a glass of orange juice or nonfat milk: Once the patient is awake and able to swallow, give a quick source of oral carbohydrate (juice or milk) followed by a snack to replenish glycogen and prevent rebound hypoglycemia.

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A patient is receiving thrombolytic therapy, and the nurse monitors the patient for adverse effects. What is the most common undesirable effect of thrombolytic therapy?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is reinforcing teaching for a patient who is on four injections of regular insulin daily. About how many hours after each injection of insulin should the nurse teach the patient to be alert for symptoms of hypoglycemia?

Correct Answer is D

Explanation

Intramuscular glucagon is administered to an unresponsive patient for treatment of hypoglycemia. Which action should the nurse take after the patient regains consciousness?

Correct Answer is D

Explanation

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