A client is receiving an infusion of alteplase (Activase) for an ...

[TVarnum]

A client is receiving an infusion of alteplase (Activase) for an intra-arterial clot. The client begins to mumble and is disoriented. What action by the nurse takes priority?
 
  a. Assess the client's neurologic status.
  b. Notify the Rapid Response Team.
  c. Prepare to administer vitamin K.
  d. Turn down the infusion rate.

Question 2

A client had a femoropopliteal bypass graft with a synthetic graft. What action by the nurse is most important to prevent wound infection?
 
  a. Appropriate hand hygiene before giving care
  b. Assessing the client's temperature every 4 hours
  c. Clean technique when changing dressings
  d. Monitoring the client's daily white blood cell count

[Missbam101]

Answer to Question 1

ANS: B
Clients on fibrinolytic therapy are at high risk of bleeding. The sudden onset of neurologic signs may indicate the client is having a hemorrhagic stroke. The nurse does need to complete a thorough neurological examination, but should first call the Rapid Response Team based on the client's manifestations. The nurse notifies the Rapid Response Team first. Vitamin K is not the antidote for this drug. Turning down the infusion rate will not be helpful if the client is still receiving any of the drug.

Answer to Question 2

ANS: A
Hand hygiene is the best way to prevent infections in hospitalized clients. Dressing changes should be done with sterile technique. Assessing vital signs and white blood cell count will not prevent infection.

[TVarnum]

Gracias!

[jordangronback]

TYSM