Alteplase (Activase) is prescribed for a client with an acute ...

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Alteplase (Activase) is prescribed for a client with an acute myocardial infarction. Which is the priority nursing intervention for this client?
 
  1. Monitor APTT.
  2. Monitor PT/INR.
  3. Monitor injection sites.
  4. Monitor level of consciousness (LOC).

Question 2

An adult client is brought to the emergency department (ED) and diagnosed with a thrombotic stroke. The team plans to administer alteplase (Activase).
 
  The client makes the following comments to a nurse. Which information is critical for the nurse to relay to the health care provider?
  1. I can't believe this is happening. My baby is only a year old.
  2. I thought this was just my asthma acting up.
  3. I wonder if this was happening when I fell and hit my head last week.
  4. I had a blood clot in my leg last year after my baby was born.

[mmpiza]

Answer to Question 1

Correct Answer: 4
Rationale 1: Thrombolytics do not affect APTT.
Rationale 2: Thrombolytics do not affect PT/INR.
Rationale 3: Thrombolytics can cause bleeding from the IV site, but that is not as important as is cerebral hemorrhage.
Rationale 4: Thrombolytics dissolve any clots they encounter. Cerebral hemorrhage is a major concern, so the nurse must assess the level of consciousness and neurological status.
Global Rationale: Thrombolytics dissolve any clots they encounter. Cerebral hemorrhage is a major concern, so the nurse must assess the level of consciousness and neurological status. Thrombolytics do not affect APTT or PT/INR. Thrombolytics can cause bleeding from the IV site, but that is not as important as is cerebral hemorrhage.

Answer to Question 2

Correct Answer: 3
Rationale 1: Childbirth a year ago is not a contraindication to alteplase (Activase).
Rationale 2: Asthma is not a contraindication to alteplase (Activase).
Rationale 3: The use of alteplase (Activase) increases the risk of severe bleeding. Clients with head injury can experience intracranial bleeding, which can cause brain damage and is potentially fatal.
Rationale 4: DVT is not a contraindication to the use of alteplase (Activase).
Global Rationale: The use of alteplase (Activase) increases the risk of severe bleeding. Clients with head injury can experience intracranial bleeding, which can cause brain damage and is potentially fatal. Childbirth a year ago, a history of asthma, and DVT are not contraindications to alteplase (Activase).

[jace]

TYSM

[zacnyjessica]

Excellent