A client who has just experienced a pulmonary embolism is administered alteplase (Activase). Which of the following side effects associated with this medication would the nurse assess for?
pancytopenia
Hypertension
Hypokalemia
Internal bleeding
The Correct Answer is D
A) Pancytopenia: While some medications can cause pancytopenia, it is not a common or direct side effect of alteplase. This condition involves a reduction in red blood cells, white blood cells, and platelets, and is not typically associated with thrombolytics.
B) Hypertension: Alteplase is not known to cause hypertension. In fact, the goal of administering alteplase in the context of a pulmonary embolism is to dissolve the clot and restore normal blood flow, which may help stabilize blood pressure.
C) Hypokalemia: This condition, characterized by low potassium levels, is not a common side effect of alteplase. There are other medications that may cause electrolyte imbalances, but alteplase itself is not typically linked to hypokalemia.
D) Internal bleeding: This is a significant risk associated with alteplase, as it is a thrombolytic agent that dissolves clots. The nurse should closely monitor for signs of internal bleeding, such as changes in vital signs, unexplained bruising, or blood in urine or stool. This is the most critical side effect to assess for in a client receiving alteplase
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Correct Answer is ["D","E"]
Explanation
A) Aspirin: While aspirin is an antiplatelet medication that can help prevent further clot formation, it does not have thrombolytic properties and does not directly lyse existing clots. Therefore, it is not appropriate for this purpose.
B) Heparin: Heparin is an anticoagulant used to prevent the extension of existing clots and reduce the risk of new clots forming, but it does not dissolve existing clots. It helps manage deep vein thrombosis but does not have thrombolytic activity.
C) Warfarin (Coumadin): Warfarin is an oral anticoagulant that is used to prevent new clot formation and the growth of existing clots. However, like heparin, it does not actively lyse or dissolve existing clots.
D) Alteplase (Activase): This medication is a thrombolytic agent that actively dissolves blood clots by activating plasminogen to plasmin, leading to clot breakdown. It is appropriate for use in cases of deep vein thrombosis when clot lysis is indicated.
E) Anistreplase (Eminase): Similar to alteplase, anistreplase is another thrombolytic agent used to lyse existing clots. It acts by converting plasminogen to plasmin, effectively breaking down fibrin in clots, making it suitable for the treatment of deep vein thrombosis.
Correct Answer is D
Explanation
A) Pulse oximetry of 92%: While a pulse oximetry reading of 92% is slightly below normal, it is not a definitive reason to hold verapamil. This reading indicates mild hypoxemia, but it does not directly contraindicate the use of verapamil. Other factors should be considered before making a decision based solely on this value.
B) Pulse of 78: A pulse rate of 78 beats per minute is within the normal range for adults and does not warrant holding verapamil. This finding alone does not indicate any immediate concerns related to the administration of the medication.
C) Respiratory rate of 12: A respiratory rate of 12 breaths per minute is within the normal range for adults. This finding does not provide any indication that verapamil should be withheld. It is important to consider other clinical factors when assessing the appropriateness of medication administration.
D) History of myocardial infarction a week ago: Verapamil, a calcium channel blocker, can have significant effects on cardiac function. Administering it to a client who recently experienced a myocardial infarction (heart attack) could exacerbate cardiac issues and lead to complications. Therefore, it is crucial to hold the medication and consult with the healthcare provider before proceeding.