Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who has pulmonary embolism and is receiving alteplase via continuous IV infusion.The nurse should monitor for which adverse effects of this medication? (Select all that apply.)
A. Hypotension
Choice A is wrong because hypotension is not a common adverse effect of alteplase. Hypotension may occur due to blood loss from bleeding or other causes, such as dehydration, sepsis, or cardiac dysfunction.
B. Bleeding
Alteplase is a fibrinolytic agent that dissolves blood clots and restores blood flow. However, it also increases the risk of bleeding from any site, such as the nose, gums, injection sites, or internal organs. Therefore, the nurse should monitor the client for signs of bleeding, such as bruising, hematuria, hematemesis, melena, or decreased hemoglobin and hematocrit levels.
C. Dysrhythmias
Choice C is wrong because dysrhythmias are not a common adverse effect of alteplase. Dysrhythmias may occur due to pulmonary embolism itself, which can cause hypoxia, acidosis, and increased pulmonary artery pressure.
D. Nausea
Choice D is wrong because nausea is not a common adverse effect of alteplase. Nausea may occur due to other factors, such as anxiety, pain, or medications.
E. Fever.
Choice E is wrong because fever is not a common adverse effect of alteplase.Fever may occur due to infection, inflammation, or other causes.
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Full Explanation
Alteplase is a fibrinolytic agent that dissolves blood clots and restores blood flow. However, it also increases the risk of bleeding from any site, such as the nose, gums, injection sites, or internal organs. Therefore, the nurse should monitor the client for signs of bleeding, such as bruising, hematuria, hematemesis, melena, or decreased hemoglobin and hematocrit levels.
Choice A is wrong because hypotension is not a common adverse effect of alteplase. Hypotension may occur due to blood loss from bleeding or other causes, such as dehydration, sepsis, or cardiac dysfunction.
Choice C is wrong because dysrhythmias are not a common adverse effect of alteplase. Dysrhythmias may occur due to pulmonary embolism itself, which can cause hypoxia, acidosis, and increased pulmonary artery pressure.
Choice D is wrong because nausea is not a common adverse effect of alteplase. Nausea may occur due to other factors, such as anxiety, pain, or medications.
Choice E is wrong because fever is not a common adverse effect of alteplase. Fever may occur due to infection, inflammation, or other causes.
Similar Questions
A nurse is caring for a client who has atrial fibrillation and is receiving warfarin therapy to prevent thromboembolism formation. The nurse should monitor which of the following laboratory values to determine the effectiveness of the medication?
A. Activated partial thromboplastin time (aPTT)
Activated partial thromboplastin time (aPTT) is wrong because it is used to monitor heparin therapy, not warfarin therapy. Heparin is another anticoagulant that works by activating antithrombin III, which inhibits thrombin and factor Xa.The therapeutic range for aPTT is 1.5 to 2.5 times the normal value, which is 30 to 40 seconds.
B. Prothrombin time (PT)
Prothrombin time (PT) is wrong because it is not a standardized measure of the warfarin effect. The PT can vary depending on the reagents and methods used by different laboratories.The INR was developed to eliminate this variability and provide a consistent measure of the warfarin effect.
C. International normalized ratio (INR)
Warfarin is an anticoagulant that inhibits the synthesis of vitamin K-dependent clotting factors. The INR is a standardized measure of the prothrombin time (PT), which reflects the degree of anticoagulation.The therapeutic range for INR is 2 to 3 for most conditions, and higher for some mechanical heart valves.
D. Platelet count.
Platelet count is wrong because it is not affected by warfarin therapy. Warfarin does not affect the number or function of platelets, only the clotting factors.Platelet count can be used to monitor other conditions that affect hemostasis, such as thrombocytopenia or thrombocytosis.
Full Explanation
Warfarin is an anticoagulant that inhibits the synthesis of vitamin K-dependent clotting factors. The INR is a standardized measure of the prothrombin time (PT), which reflects the degree of anticoagulation. The therapeutic range for INR is 2 to 3 for most conditions, and higher for some mechanical heart valves.
Choice A) Activated partial thromboplastin time (aPTT) is wrong because it is used to monitor heparin therapy, not warfarin therapy.
Heparin is another anticoagulant that works by activating antithrombin III, which inhibits thrombin and factor Xa. The therapeutic range for aPTT is 1.5 to 2.5 times the normal value, which is 30 to 40 seconds.
Choice B) Prothrombin time (PT) is wrong because it is not a standardized measure of the warfarin effect.
The PT can vary depending on the reagents and methods used by different laboratories. The INR was developed to eliminate this variability and provide a consistent measure of the warfarin effect.
Choice D) Platelet count is wrong because it is not affected by warfarin therapy.
Warfarin does not affect the number or function of platelets, only the clotting factors. Platelet count can be used to monitor other conditions that affect hemostasis, such as thrombocytopenia or thrombocytosis.
A nurse is caring for a client who has deep vein thrombosis and is receiving enoxaparin therapy subcutaneously once daily at home. The nurse should instruct the client to report which of the following findings immediately?
A. Bruising at injection site
Bruising at injection site is wrong because bruising is a common and expected side effect of enoxaparin therapy, especially if the client is using the same injection site repeatedly. The client should be instructed to rotate the injection sites and apply gentle pressure after each injection to minimize bruising.
B. Redness at injection site
Redness at injection site is wrong because redness is also a common and expected side effect of enoxaparin therapy, as it indicates a local inflammatory response to the medication. The client should be advised to avoid rubbing or scratching the injection site and to apply a cold compress if needed.
C. Swelling in one leg
This is because swelling in one leg could indicate a new or worsening deep vein thrombosis (DVT), which is a serious condition that can lead to pulmonary embolism or other complications. The client should report this finding to the provider immediately and seek medical attention.
D. Mild pain at injection site.
Mild pain at injection site is wrong because mild pain is also a common and expected side effect of enoxaparin therapy, as it reflects the needle insertion and the medication delivery. The client should be reassured that the pain will subside shortly and to use a different injection site for the next dose.
Full Explanation
This is because swelling in one leg could indicate a new or worsening deep vein thrombosis (DVT), which is a serious condition that can lead to pulmonary embolism or other complications. The client should report this finding to the provider immediately and seek medical attention.
Choice A) Bruising at injection site is wrong because bruising is a common and expected side effect of enoxaparin therapy, especially if the client is using the same injection site repeatedly.
The client should be instructed to rotate the injection sites and apply gentle pressure after each injection to minimize bruising.
Choice B) Redness at injection site is wrong because redness is also a common and expected side effect of enoxaparin therapy, as it indicates a local inflammatory response to the medication.
The client should be advised to avoid rubbing or scratching the injection site and to apply a cold compress if needed.
Choice D) Mild pain at injection site is wrong because mild pain is also a common and expected side effect of enoxaparin therapy, as it reflects the needle insertion and the medication delivery.
The client should be reassured that the pain will subside shortly and to use a different injection site for the next dose.
Normal ranges for enoxaparin therapy are based on the client’s weight, indication, and renal function.
The usual dose for DVT prophylaxis is 40 mg subcutaneously once daily, and the usual dose for DVT treatment is 1 mg/kg subcutaneously every 12 hours.
The client should have regular blood tests to monitor the anti-factor Xa level, which should be between 0.5 and 1.0 IU/mL for DVT prophylaxis and between 0.6 and 1.0 IU/mL for DVT treatment.
The client should also have regular platelet counts to check for heparin-induced thrombocytopenia (HIT), which is a rare but serious complication of enoxaparin therapy that causes a drop in platelets and an increased risk of thrombosis.
The normal platelet count range is 150,000 to 450,000/mm3.
A client who has atrial fibrillation is prescribed dabigatran etexilate mesylate (Pradaxa). The nurse should instruct the client to report which of the following findings immediately? (Select all that apply.)
A. Unusual bleeding or bruising
Dabigatran etexilate mesylate (Pradaxa) is a medication that prevents blood clots and reduces the risk of stroke in patients with atrial fibrillation. However, it can also cause bleeding as a side effect. Therefore, the nurse should instruct the client to report any signs of unusual bleeding or bruising, blood in urine or stool, or abdominal pain or swelling immediately.These could indicate a serious complication such as gastrointestinal bleeding, hemorrhage, or internal organ damage.
B. Blood in urine or stool
Dabigatran etexilate mesylate (Pradaxa) is a medication that prevents blood clots and reduces the risk of stroke in patients with atrial fibrillation. However, it can also cause bleeding as a side effect. Therefore, the nurse should instruct the client to report any signs of unusual bleeding or bruising, blood in urine or stool, or abdominal pain or swelling immediately.These could indicate a serious complication such as gastrointestinal bleeding, hemorrhage, or internal organ damage.
C. Abdominal pain or swelling
Dabigatran etexilate mesylate (Pradaxa) is a medication that prevents blood clots and reduces the risk of stroke in patients with atrial fibrillation. However, it can also cause bleeding as a side effect. Therefore, the nurse should instruct the client to report any signs of unusual bleeding or bruising, blood in urine or stool, or abdominal pain or swelling immediately.These could indicate a serious complication such as gastrointestinal bleeding, hemorrhage, or internal organ damage.
D. Headache or dizziness
Choice D, headache or dizziness, is not a correct answer. Although these symptoms could be caused by dabigatran, they are not as serious or urgent as bleeding. They could also be due to other factors such as dehydration, low blood pressure, or stress.The nurse should advise the client to monitor these symptoms and seek medical attention if they persist or worsen.
E. Shortness of breath.
Choice E, shortness of breath, is not a correct answer. Shortness of breath is not a common side effect of dabigatran. However, it could be a symptom of atrial fibrillation or its complications such as heart failure or stroke.The nurse should educate the client about the signs and symptoms of these conditions and instruct them to call 911 if they experience chest pain, palpitations, fainting, or weakness.
Full Explanation
Dabigatran etexilate mesylate (Pradaxa) is a medication that prevents blood clots and reduces the risk of stroke in patients with atrial fibrillation.
However, it can also cause bleeding as a side effect.
Therefore, the nurse should instruct the client to report any signs of unusual bleeding or bruising, blood in urine or stool, or abdominal pain or swelling immediately. These could indicate a serious complication such as gastrointestinal bleeding, hemorrhage, or internal organ damage.
Choice D, headache or dizziness, is not a correct answer.
Although these symptoms could be caused by dabigatran, they are not as serious or urgent as bleeding.
They could also be due to other factors such as dehydration, low blood pressure, or stress. The nurse should advise the client to monitor these symptoms and seek medical attention if they persist or worsen.
Choice E, shortness of breath, is not a correct answer.
Shortness of breath is not a common side effect of dabigatran.
However, it could be a symptom of atrial fibrillation or its complications such as heart failure or stroke. The nurse should educate the client about the signs and symptoms of these conditions and instruct them to call 911 if they experience chest pain, palpitations, fainting, or weakness.