A client weighing 105\text{ kg} is admitted to the emergency department with an acute isch… — NCLEX-RN

A client weighing $105\text{ kg}$ is admitted to the emergency department with an acute ischemic stroke. The healthcare provider prescribes intravenous alteplase therapy at $0.9\text{ mg/kg}$ . Which of the following nursing actions are required for the safe administration and monitoring of this pharmacological therapy? (Select all that apply.)

Administer $10\%$ of the calculated total alteplase dose as an intravenous bolus over $1\text{ minute}$ prior to starting the continuous infusion.Cevap
B
Prepare to administer a total alteplase dose of $94.5\text{ mg}$ based on the client's admission weight.
C
Piggyback the alteplase infusion into an existing primary intravenous line running $0.9\%$ sodium chloride with $20\text{ mEq/L}$ of potassium chloride.
D
Perform neurological assessments and monitor vital signs every $30\text{ minutes}$ during the continuous infusion phase.
Delay the insertion of indwelling urinary catheters, nasogastric tubes, or intra-arterial catheters for at least $24\text{ hours}$ after the infusion.Cevap
Administer prescribed intravenous labetalol if the client's systolic blood pressure exceeds $180\text{ mm Hg}$ during the infusion.Cevap

Cevap

The safe administration of alteplase requires giving

10\%

of the total maximum

90\text{ mg}

dose as a

1\text{-minute}

bolus, strictly controlling systolic blood pressure below

180\text{ mm Hg}

, and avoiding any invasive procedures for at least

24\text{ hours}

to prevent severe bleeding complications.

Safe alteplase administration involves giving

10\%

of the total dose as a bolus over

1\text{ minute}

, strictly managing blood pressure (systolic <

180\text{ mm Hg}

) with rapid-acting antihypertensives, and minimizing bleeding risks by delaying invasive procedures (like catheter insertions) for

24\text{ hours}

Adım Adım Çözüm

Calculate the safe medication dosage, recognizing the absolute maximum limit.

The calculated dose for a

105\text{ kg}

client is

94.5\text{ mg}

, but the absolute maximum allowable dose must be capped at

90\text{ mg}

Exceeding the

90\text{ mg}

maximum dose significantly increases the risk of fatal intracranial hemorrhage, regardless of the client's actual body weight.

Determine the proper administration method and rate.

The protocol dictates that

10\%

of the total dose is given as an IV bolus over

1\text{ minute}

, with the remaining

90\%

infused continuously over

60\text{ minutes}

This biphasic administration is required to quickly achieve and then safely maintain therapeutic thrombolytic blood levels.

Establish a dedicated intravenous line.

Alteplase must run through its own dedicated line, not piggybacked with other medications like potassium chloride.

Alteplase is physically incompatible with many medications and requires uninterrupted, precise infusion rates.

Implement required safety monitoring protocols during and after the infusion.

Neurological status and vital signs must be checked every

15\text{ minutes}

, blood pressure must be kept below

180/105\text{ mm Hg}

, and all invasive procedures must be delayed.

These measures are critical to promptly identify hemorrhagic conversion and minimize bleeding risks while the systemic thrombolytic effect is active.

Anahtar Kavram

Alteplase (tPA) Administration and Monitoring Protocol

Soru

Cevap

Adım Adım Çözüm

Anahtar Kavram

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