Question

Alteplase (Activase/tPA) is prescribed for a client who is experiencing an acute myocardial infarction. What priority assessment should the nurse perform?

Select one:
a. Monitoring for signs of infection.
b. Monitoring bowel sounds.
c. Monitoring level of consciousness (LOC).
d. Monitoring for muscle pain.

Answer 1

In the event of an acute myocardial infarction where Alteplase is administered, monitoring the patient's level of consciousness is the priority to quickly identify any adverse effects or complications.

Step-by-step explanation:

The priority assessment a nurse should perform when a client is experiencing an acute myocardial infarction and is prescribed Alteplase (Activase/tPA), a thrombolytic agent, is monitoring level of consciousness (LOC). This is crucial as it can indicate the development of complications, such as intracranial hemorrhage, which is a contraindication for thrombolytic therapy and a potential side effect. Alteplase helps to speed up the degradation of an abnormal clot by converting plasminogen to plasmin, the primary enzyme that breaks down clots, thereby aiding in restoring normal blood flow.