A client with myocardial infarction is receiving tissue plasminogen activator, alteplase (Activase, tPA). While on the therapy, the nurse plans to prioritize which of the following?
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Solution
Observe for signs of bleeding.
Bleeding is the priority concern for a client taking thrombolytic medication.
Options A and B are monitored but are not the primary concern.
Option C is not related to the use of medication.
A client is receiving Procainamide (Procanbid) for the treatment of ventricular arrhythmia. The client suddenly complains of nausea and drowsiness. Which of the intervention should the nurse do first?
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Solution
Check the blood pressure and heart rate.
The client is experiencing signs of procainamide toxicity, the priority nursing action is to obtain vital signs immediately.
Options B and C are done after checking the vital signs.
Option D will cause hypotension.
A nurse is providing health teachings regarding antiplatelet medications. Which of the following is not true regarding the use of this medication?
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Solution
Antiplatelet medications cannot be used with anticoagulants.
Antiplatelet and anticoagulant therapies are effective in keeping a clot from forming or stopping the growth of one.
A client who is receiving streptokinase therapy suddenly had a nose bleeding. The nurse ensures the availability in which of the following medication?
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Solution
Aminocaproic acid (Amicar).
Bleeding can be reversed with the use of aminocaproic acid as an antidote for streptokinase.
Option A is the antidote for warfarin sodium toxicity.
Option B is the antidote for iron toxicity.
Option D is an antihistamine that can be used for any allergic reaction.
A client with deep vein thrombosis is receiving Streptokinase (Streptase). The nurse would notify the physician if which of the following assessment is noted?
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Solution
A blood pressure of 185/100 mm Hg.
Thrombolytic therapy is contraindicated with uncontrolled hypertension (systolic BP >180 mm Hg and/or diastolic BP >110 mm Hg) because of the risk of cerebral hemorrhage.
Options A, B, and C may be present during the therapy but will not warrant the immediate knowledge of the physician before starting the therapy.
A client is receiving a continuous infusion of streptokinase (Streptase). The client suddenly complaints of a difficulty of breathing, itchiness, and nausea. Which of the following should be the priority action of the nurse?
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Solution
Stop the infusion and call the physician.
Severe allergic reaction to streptokinase requires immediate discontinuation of Streptokinase,then notify the physician and administer an adrenergic, antihistamine, and/or corticosteroid agents as ordered.
A client is receiving intravenous heparin therapy. The nurse ensures the availability in which of the following medication?
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Solution
Protamine sulfate.
Protamine sulfate is the antidote that reverses the anticoagulant effects of heparin by binding to it.
Option A is the antidote for acetaminophen toxicity.
Option B is the antidote for magnesium sulfate toxicity.
Option C is the antidote for warfarin sodium toxicity.
A client with atrial fibrillation is receiving a continuous heparin infusion at 1,000 units/hr. The nurse observes that the client is receiving the therapeutic effect based on which of the following results?
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Solution
Activated partial thromboplastin time of 60 seconds.
The normal range for activated partial thromboplastin time is 20-36 seconds. The activated partial thromboplastin time must be 1.5 to 2.5 times the normal value, the client’s Appt would be considered therapeutic if it was 60 seconds.
A nurse is caring for a client receiving a heparin intravenous (IV) infusion. The nurse expects that which of the following laboratory will be prescribed to monitor the therapeutic effect of heparin?
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Solution
Activated partial thromboplastin time (aPTT).
Activated partial thromboplastin time assess the therapeutic level of heparin.
Option A: Assess the therapeutic level of warfarin sodium (Coumadin).
Options C and D: Measures the aspect of the red blood cells.
A nurse is providing instructions to a client who is receiving warfarin sodium (Coumadin). Which statement made by the client indicates the need for further instruction?
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Solution
“I will take Ecotrin (Enteric coated aspirin) for my headaches”.
Ecotrin is an aspirin-containing product and should be avoided due to the risk of bleeding.