A client with a large pulmonary embolism is receiving alteplase (Activase). The nurse notes frank red blood in the Foley catheter drainage bag. What is the nurse's first action?
a. Irrigate the Foley.
b. Administer an antibiotic.
c. Clamp the Foley.
d. Notify the health care provider.
D
Alteplase is a fibrinolytic agent that dissolves formed clots. The drug has an impact on clots out-side the pulmonary embolism, and the client is at great risk for hemorrhage and shock. The nurse should realize the potential for a severe problem and should call the health care provider imme-diately for orders. The other actions would not be appropriate first actions in this situation.
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