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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?
- A. Dysrhythmias
- B. Nausea and vomiting
- C. Anaphylactic reactions
- D. Internal and superficial bleeding
Correct Answer: D
Rationale: The most common undesirable effect of thrombolytic therapy is bleeding, both internal and superficial. Thrombolytic agents work by dissolving blood clots, which can lead to an increased risk of bleeding. Patients receiving thrombolytic therapy should be closely monitored for signs of bleeding, such as easy bruising, petechiae, hematomas, or gastrointestinal bleeding. It is essential for healthcare providers to assess and manage the risk of bleeding while administering thrombolytic therapy to minimize potential complications. Dysrhythmias, nausea and vomiting, and anaphylactic reactions are less common adverse effects of thrombolytic therapy compared to bleeding.
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Which of the following has the shortest elimination half-life?
- A. Naloxone
- B. Morphine
- C. Methadone
- D. Remifentanil
Correct Answer: D
Rationale: Elimination half-life measures how quickly a drug is cleared from plasma. Naloxone's half-life is about 1-2 hours, used for opioid reversal. Morphine's is 2-4 hours, reflecting its duration as an analgesic. Methadone's is long, 15-60 hours, suiting addiction maintenance. Fentanyl's is 2-4 hours, typical for anesthesia. Remifentanil, an ultra-short-acting opioid, has a half-life of 3-10 minutes due to rapid esterase metabolism, making it ideal for procedures needing quick offset. Its brevity contrasts with others, ensuring minimal residual effects, a key advantage in critical care settings where rapid recovery is essential.
When preparing to administer IV Acyclovir for Herpes Zoster, what action should the nurse take?
- A. Infuse the medication over 1 hour.
- B. Monitor the client's blood pressure every 15 minutes during infusion.
- C. Administer a stool softener.
- D. Monitor the client's blood glucose level every 4 hours during infusion.
Correct Answer: A
Rationale: The correct action for the nurse is to infuse IV Acyclovir over at least 1 hour to prevent nephrotoxicity. Rapid infusion can lead to adverse effects, so a slow infusion rate is crucial for patient safety. Monitoring blood pressure, administering a stool softener, or monitoring blood glucose levels are not directly related to the administration of IV Acyclovir for Herpes Zoster.
A client with cirrhosis is about to receive a dose of lactulose. The client questions the need for the medication, stating they are not constipated. The nurse should explain that lactulose is used in cirrhosis to reduce levels of which component in the bloodstream?
- A. Glucose
- B. Ammonia
- C. Potassium
- D. Bicarbonate
Correct Answer: B
Rationale: Lactulose is administered to clients with cirrhosis to lower blood ammonia levels, thus aiding in the prevention of hepatic encephalopathy. Elevated ammonia levels in cirrhosis can lead to cognitive impairment and hepatic encephalopathy. Therefore, the correct answer is B (Ammonia). Glucose (Choice A) is not the component targeted by lactulose in cirrhosis. Potassium (Choice C) and Bicarbonate (Choice D) are not directly affected by lactulose administration in cirrhosis.
A client has a new prescription for colchicine to treat gout. Which of the following instructions should be included?
- A. Take this medication with food if nausea develops.
- B. Monitor for muscle pain.
- C. Expect to have increased bruising.
- D. Increase your intake of grapefruit juice.
Correct Answer: B
Rationale: Monitoring for muscle pain is crucial when taking colchicine because it can lead to rhabdomyolysis, a serious condition characterized by muscle breakdown. This adverse effect needs prompt identification to prevent complications. Choices A, C, and D are incorrect because taking colchicine with food, experiencing increased bruising, or increasing grapefruit juice intake are not relevant instructions for a client prescribed colchicine for gout.
A client with thrombophlebitis receiving heparin by continuous IV infusion asks the nurse how long it will take for the heparin to dissolve the clot. Which of the following responses should the nurse give?
- A. It usually takes heparin at least 2 to 3 days to reach a therapeutic blood level.
- B. A pharmacist is the person to answer that question.
- C. Heparin does not dissolve clots. It stops new clots from forming.
- D. The oral medication you will take after this IV will dissolve the clot.
Correct Answer: C
Rationale: The correct response is C. Heparin does not dissolve clots; it prevents new clots from forming. Heparin works by inhibiting the formation of new clots and the extension of existing clots, rather than directly dissolving them. The client should be informed that the purpose of heparin therapy is to prevent the clot from getting larger and to reduce the risk of new clots forming. Choices A, B, and D are incorrect. Choice A talks about reaching a therapeutic blood level of heparin, which is not related to clot dissolution. Choice B deflects the question to a pharmacist without providing relevant information. Choice D inaccurately suggests that an oral medication will dissolve the clot, which is not the mechanism of action for heparin.