Symptomatic Bradycardia

A nurse is caring for a 60-year-old male client in the medical-surgical unit who was recently admitted with symptomatic bradycardia and has undergone permanent pacemaker insertion.

Complete the following sentence by using the list of options.
The nurse is caring for the client immediately following the insertion of the permanent pacemaker. The nurse should monitor the client for

_________

and

__________

.

Choice A rationale

Alteplase (tPA) is a thrombolytic agent, meaning it dissolves existing blood clots by activating plasminogen to form plasmin, which then breaks down fibrin. It is used to treat acute thrombotic events like pulmonary embolism or ischemic stroke, but it is not typically used for prophylactic prevention of DVT due to its significant bleeding risk.

Choice B rationale

Enoxaparin is a low molecular weight heparin (LMWH). It exerts its anticoagulant effect primarily by potentiating the action of antithrombin on Factor Xa, thereby inhibiting the coagulation cascade. LMWHs are highly effective and commonly used for the prophylactic prevention of deep vein thrombosis following orthopedic surgeries, including total knee replacement, due to their predictable pharmacokinetics.

Choice C rationale

Warfarin is an oral anticoagulant that works by inhibiting vitamin K epoxide reductase, an enzyme necessary for the synthesis of vitamin K-dependent clotting factors (II, VII, IX, X). While effective for long-term anticoagulation, its delayed onset of action and need for frequent INR monitoring make it less suitable for immediate postoperative DVT prophylaxis compared to LMWHs.

Choice D rationale

Clopidogrel is an antiplatelet agent that works by selectively inhibiting the binding of adenosine diphosphate (ADP) to its receptor on platelet surfaces, thereby preventing platelet activation and aggregation. It is used to prevent arterial thrombotic events like myocardial infarction and stroke, but it is not the primary medication for preventing venous thromboembolism such as DVT.

Choice A rationale: Yellow sclera indicates jaundice, a clinical sign of elevated bilirubin caused by hepatocellular damage. Isoniazid and rifampin are both hepatotoxic drugs commonly used in tuberculosis treatment. When the liver is compromised, bilirubin accumulates and is deposited in the sclera and skin. This clinical presentation requires immediate provider notification, as it may indicate early liver failure or the need to discontinue hepatotoxic medications to prevent worsening hepatic injury.

Choice B rationale: The AST level has increased from 35 to 36 units/L, reaching the upper limit of normal. Normal AST is 0–35 units/L. Although this is a slight increase, in the context of tuberculosis treatment with known hepatotoxic medications like isoniazid and rifampin, even a small upward trend can be an early warning of hepatic injury. Hepatotoxicity can progress rapidly, so any increase warrants provider notification for monitoring or possible medication adjustment.

Choice C rationale: The 3.2 kg (7 lb) weight loss is a classic symptom of tuberculosis due to increased metabolic demand and decreased appetite from systemic inflammation. However, this weight loss is already known and part of the client's initial presentation, not a new or worsening symptom. It does not require immediate provider notification unless the weight loss continues to progress or is accompanied by other signs of deterioration such as hypotension or electrolyte imbalance.

Choice D rationale: The Mantoux test showed a 12 mm induration, which is considered positive in individuals with risk factors like recent travel or suggestive radiographic findings. However, a positive Mantoux alone is not urgent, especially when TB has already been suspected and treatment has been initiated. It confirms exposure but does not require immediate provider notification unless being used for new diagnosis initiation. The result is consistent with the working diagnosis of tuberculosis.

Choice E rationale: ALT increased from 36 to 38 SI/L, exceeding the upper limit of normal (4–36 SI/L). ALT is a liver-specific enzyme, and its elevation strongly suggests hepatocellular injury. Both isoniazid and rifampin are known to elevate ALT levels. Even a minor elevation in ALT in this context may be the beginning of drug-induced hepatitis, which can progress without early intervention. Prompt reporting is needed to assess medication risks and protect liver function.

Choice F rationale: Reddish-orange urine is a well-documented, harmless side effect of rifampin. This medication binds to chromophores and imparts a discoloration to urine, sweat, tears, and saliva. It is not a sign of renal dysfunction or drug toxicity. Patient education on this harmless but expected effect is important, but it does not require provider notification. Misinterpretation may cause alarm, but the discoloration is entirely benign and anticipated during rifampin therapy.