A client having a myocardial infarction is receiving alteplase ...

[abern]

A client having a myocardial infarction is receiving alteplase (Activase) therapy. Which of the following actions should be carried out by the nurse to monitor for the most frequent adverse effect?
 
  1. Monitor for bleeding.
  2. Assess for allergic reaction.
  3. Evaluate the client for muscle weakness.
  4. Monitor for signs and symptoms of infection.

Question 2

The nurse is preparing a continuous intravenous (IV) infusion at the medication cart. As the nurse prepares to attach the distal end of the IV tubing to a needleless device, the tubing drops and hits the top of the medication cart.
 
  Which of the following is the appropriate action by the nurse? 1. Change the IV tubing.
  2. Attach a new needleless device.
  3. Wipe the tubing port with Betadine.
  4. Scrub the needleless device with an alcohol swab.

[smrtceo]

Answer to Question 1

1

Rationale: Alteplase is a thrombolytic medication, which means that it breaks down or dissolves clots; therefore, bleeding is a concern. Local or systemic infection could occur with poor aseptic technique during medication administration, but it is rare. Allergic reaction is not a frequent response. Muscle weakness is not an adverse effect of this medication.

Answer to Question 2

1

Rationale: The nurse should change the IV tubing because it has become contaminated and could cause systemic infection to the client. Wiping the port with Betadine is insufficient and would be contraindicated in any case, because the tubing will be attached directly to an angio-catheter in the client's vein. The needleless device has not been contaminated and does not need replacement or cleansing.

[abern]

TYSM

[abro1885]

Gracias!