A patient is receiving thrombolytic therapy, and the nurse monitors the patient for adverse effects. What is the most common undesirable effect of thrombolytic therapy?

Correct Answer: D

Rationale: The most common undesirable effect of thrombolytic therapy is internal and superficial bleeding. Thrombolytic medications work by dissolving blood clots, which can lead to an increased risk of bleeding. This bleeding can occur internally, such as in the gastrointestinal tract or brain, or externally, in the form of bruising or easy bleeding from cuts or wounds. It is crucial for healthcare providers to closely monitor patients receiving thrombolytic therapy for signs of bleeding and to promptly address any concerns to prevent complications. Dysrhythmias, nausea and vomiting, and anaphylactic reactions are less common adverse effects associated with thrombolytic therapy compared to bleeding.

Correct Answer: A

Rationale: In this scenario, with the patient experiencing leg pain while taking atorvastatin (Lipitor), a medication commonly used to treat high cholesterol, it is essential to prioritize the patient's safety and well-being. Leg pain can be a sign of a rare but serious side effect known as rhabdomyolysis, which can lead to muscle breakdown and potentially affect kidney function. Therefore, it is crucial to immediately discontinue the medication (atorvastatin) and have the patient come in to the clinic to be seen today for further evaluation and management. This will allow healthcare providers to assess the severity of the leg pain, conduct necessary tests, and determine the appropriate course of action to ensure the patient's health and safety.

Correct Answer: A

Rationale: When taking Digoxin, low levels of potassium can cause toxicity because digoxin competes with potassium for binding sites on the sodium-potassium pump in cardiac cells. Low potassium levels can lead to increased binding of digoxin to the pump, resulting in increased intracellular calcium levels and an increased risk of digoxin toxicity, including arrhythmias. Therefore, monitoring and maintaining adequate potassium levels are crucial in patients taking digoxin to prevent toxicity.

Correct Answer: A

Rationale: To evaluate the medical effectiveness of Metformin, it is essential to monitor serum glucose levels, as Metformin is commonly used to treat type 2 diabetes by decreasing glucose production in the liver and increasing insulin sensitivity in peripheral tissues. Monitoring serum electrolytes, ketones, blood pH, lactate, and pyruvate levels is also important because Metformin can potentially cause lactic acidosis, especially in patients with kidney or liver impairment. By assessing these parameters, healthcare providers can gauge the efficacy and safety of Metformin therapy. Checking for resolution of hypothyroidism and hormone normalization is not directly related to evaluating Metformin's effectiveness. Pain reduction and patient alertness are also not the primary indicators for assessing the medical effectiveness of Metformin in managing diabetes.

Correct Answer: B

Rationale: The high alert nursing implication for Morphine is to assess the level of consciousness, blood pressure, pulse, and respiration. Morphine is a potent opioid analgesic that can cause respiratory depression, sedation, and hypotension as side effects. Monitoring the patient's vital signs and neurological status is crucial to detect any signs of overdose or adverse reactions promptly. Maintaining vigilant observation of these parameters can help prevent serious complications and ensure the safe administration of Morphine.