ATI Ch.25

A nurse is monitoring a client who takes aspirin, 81mg PO daily. Which of the following clinical manifestations are adverse effects of daily aspirin therapy? (SATA) A. Hypertension B. Coffee ground emesis C. Tinnitus D.Paresthesias of the extremities E. Nausea

B,C,E adverse effects are hypotension, GI distress (coffee ground emesis), hearing loss (tinnitus), and nausea/vomiting

A nurse is planning to administer IV alteplase (Activase) to a client who is demonstrating manifestations of a massive pulmonary embolism. Which of the following interventions is appropriate for the nurse to plan? A. Give IM enoxaparin along with alteplase dose B. Hold direct pressure on puncture sites for up to 30 mins C. Administer aminocaproic acid (Amicar) IV prior to alteplase infusion D. Prepare to administer alteplase within 8 hours of manifestation onset

B. Hold 10-30mins or until oozing stops

A nurse is planning to administer subcutaneous enoxaparin (Lovenox) to an adult client following hip arthroplasty. Which of the following actions should the nurse plan to take? A. Choose a 22-gauge needle to administer the injection B. Use a 5/8-inch needle to administer the injection C. Administer the injection in the clients thigh D. Aspirate carefully after inserting the needle into the client's skin

B. Use a 22 gauge to withdrawl and a 5/8 inch to administer the medication. Inject into abdomen not thigh.

A nurse is caring for a client who has atrial fibrillation and is has a new prescription for dabigatran (Pradaxa) to prevent developement of thrombosis. WOTF medications is prescribed concurrently to treat an adverse effect of dabigatran? A. Vitamin K B. Protamine C. Omeprazole (Prilosec) D. Probenecid (Benemid)

C. Omeprazole (Prilosec) Proton pump inhibitors helps with the GI distress which is an adverse effect of dabigatrin.

A nurse is caring for a hospitalized client who is receiving IV heparin for a deep vein thrombosis. The client begins vomiting blood. After the heparin has been stopped, which of the following medications should the nurse prepare to administer? A. Vitamin K (Phytonadione) B. Atropine C. Protamine D. Calcium gluconate

C. Protamine reverses effects of heparin