The nurse is reviewing a client's prescribed medication list and notes that the client recently received alteplase. Which client outcome indicates the medication is effective?

Reference Range:

Prothrombin (PT) [11.0 to 12.5 seconds; 85% to 100%]

Pulmonary emboli resolved.

Central venous line patent, flushes and aspirates freely.

Prothrombin time (PT) remains 1.5 times higher than the control.

No deep venous thrombosis.

Answer and Explanation

The Correct Answer is A

Rationale:
A. Pulmonary emboli resolved: Alteplase is a thrombolytic that converts plasminogen to plasmin, leading to fibrin degradation and active clot dissolution. Resolution of an existing thrombus, such as a pulmonary embolism, directly reflects the intended pharmacologic effect. Clinical or imaging evidence of clot resolution indicates therapeutic success.

B. Central venous line patent, flushes and aspirates freely: Alteplase may be used in low doses to restore catheter patency, but this outcome does not reflect systemic thrombolytic effectiveness. Catheter clearance does not indicate treatment of a pathologic thrombus. This finding is procedure-specific rather than therapeutic for thromboembolism.

C. Prothrombin time (PT) remains 1.5 times higher than the control: PT is used to monitor warfarin therapy and is not a marker of alteplase efficacy. Thrombolytics act by lysing clots rather than altering clotting factor synthesis. Changes in PT do not indicate successful fibrinolysis.

D. No deep venous thrombosis: Absence of a new DVT reflects prevention rather than active clot breakdown. Alteplase is administered to dissolve existing thrombi, not as primary prophylaxis. Lack of DVT does not demonstrate that fibrinolysis has occurred.

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Correct Answer is C

Explanation

Rationale:
A. Measure abdominal girth: Abdominal girth assessment is more relevant for monitoring ascites or abdominal distention, not for evaluating a suprapubic catheter. It does not provide information about catheter function or complications.

B. Assess perineal area: While perineal skin integrity is important, a suprapubic catheter bypasses the urethra, making perineal assessment less directly related to catheter care.

C. Observe insertion site: Inspecting the suprapubic catheter insertion site is essential to detect signs of infection, leakage, or skin breakdown. Proper site monitoring ensures early identification of complications and maintains catheter patency.

D. Palpate flank area: Flank palpation can detect kidney tenderness, which may indicate infection, but this is secondary to direct inspection of the catheter site. Immediate assessment focuses on the insertion site for safety and infection prevention.

A. Imbalanced Nutrition: less than body requirements. B. Interrupted Family Processes. C. Noncompliance with treatment regimen. D. Disturbed Body Image.

Correct Answer is A

Explanation

Rationale:
A. Imbalanced Nutrition: less than body requirements: Malnutrition is the most immediate threat to life in adolescents with anorexia nervosa. Addressing inadequate nutrition is critical to prevent complications such as electrolyte imbalances, cardiac arrhythmias, and organ failure, making it the highest priority.

B. Interrupted Family Processes: Family dysfunction can contribute to the disorder, but it is not an immediate threat to the client’s physical health. It is a secondary concern to nutritional stabilization.

C. Noncompliance with treatment regimen: Noncompliance affects long-term outcomes, but the immediate risk from malnutrition takes precedence. Interventions for compliance follow stabilization.

D. Disturbed Body Image: Body image concerns are central to anorexia nervosa but primarily affect psychosocial health. While important for therapy, they are not the most urgent nursing problem compared with physiological risk.

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The nurse is reviewing a client's prescribed medication list and notes that the client recently received alteplase. Which client outcome indicates the medication is effective? Reference Range: Prothrombin (PT) [11.0 to 12.5 seconds; 85% to 100%]

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Naxlex Comprehensive Predictor Exams

Which assessment should the home health nurse include during a routine home visit for a client who was discharged home with a suprapubic catheter?

Correct Answer is C

Explanation

When planning care for an adolescent with anorexia nervosa, which nursing problem has the highest priority?

Correct Answer is A

Explanation

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The nurse is reviewing a client's prescribed medication list and notes that the client recently received alteplase. Which client outcome indicates the medication is effective?

Reference Range:

Prothrombin (PT) [11.0 to 12.5 seconds; 85% to 100%]