Nokea
A client is diagnosed with an acute myocardial infarction and is receiving tissue plasminogen activator, alteplase (Activase, tPA). Which action is a priority nursing intervention?
- A. Monitor for renal failure.
- B. Monitor psychosocial status.
- C. Monitor for signs of bleeding.
- D. Have heparin sodium available.
Correct Answer: C
Rationale: The priority nursing intervention for a client receiving tissue plasminogen activator (alteplase) for an acute myocardial infarction is to monitor for signs of bleeding. Alteplase is a thrombolytic medication that can lead to hemorrhage as a complication. Therefore, closely monitoring the client for any signs of bleeding is essential to promptly address and manage this potential adverse effect.
You may also like to solve these questions
A client is prescribed metronidazole (Flagyl) for a trichomoniasis infection. Which of the following should the nurse include in the teaching plan?
- A. Avoid consuming alcohol while taking this medication.
- B. Take the medication with food.
- C. Increase fluid intake to prevent kidney stones.
- D. Report any gastrointestinal upset to the healthcare provider.
Correct Answer: A
Rationale: The correct answer is A. Metronidazole (Flagyl) can cause a disulfiram-like reaction when taken with alcohol, resulting in severe nausea, vomiting, and headache. Therefore, the client should be advised to avoid alcohol while taking this medication to prevent adverse effects. Avoiding alcohol is crucial to prevent these reactions and ensure the effectiveness of the treatment. The other options are not directly related to the specific medication or the condition being treated.
Which statement by the client indicates a need for further teaching about the use of metoprolol (Lopressor)?
- A. I will not stop taking the medication abruptly.
- B. I will take my pulse before taking the medication.
- C. I will take the medication with food.
- D. I will take the medication at bedtime.
Correct Answer: D
Rationale: The correct answer is D because taking metoprolol (Lopressor) at bedtime is not specifically recommended. Metoprolol should be taken with food to enhance absorption. It is crucial for the client not to stop taking the medication abruptly to prevent rebound hypertension or other adverse effects. Additionally, monitoring the pulse before taking metoprolol is important for assessing its effect on heart rate.
A clinic nurse prepares to administer an MMR (measles, mumps, rubella) vaccine to a child. How is this vaccine best administered?
- A. Intramuscularly in the deltoid muscle
- B. Subcutaneously in the gluteal muscle
- C. Subcutaneously in the outer aspect of the upper arm
- D. Intramuscularly in the anterolateral aspect of the thigh
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client with trigeminal neuralgia tells the nurse that acetaminophen (Tylenol) is taken on a frequent daily basis for relief of generalized discomfort. The nurse reviews the client's laboratory results and determines that which of the following indicates toxicity associated with the medication?
- A. Sodium of 140 mEq/L
- B. Prothrombin time of 12 seconds
- C. Platelet count of 400,000 cells/mm³
- D. A direct bilirubin level of 2 mg/dL
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Sildenafil (Viagra) is prescribed to treat a client with erectile dysfunction. A nurse reviews the client's medical record and would question the prescription if which of the following is noted in the client's history?
- A. Neuralgia
- B. Insomnia
- C. Use of nitroglycerin
- D. Use of multivitamins
Correct Answer: C
Rationale: The correct answer is C. Sildenafil (Viagra) enhances the vasodilating effect of nitric oxide and is contraindicated with the concurrent use of organic nitrates and nitroglycerin. Using nitroglycerin together with Viagra can lead to severe hypotension and cardiovascular collapse, making it unsafe to combine both medications.