A client received a thrombolytic medication following a myocardial infarction. When the client has a bowel movement, which action should the nurse implement?
Explanation & Rationale
Rationale: A. Assess for fatty yellow streaks in the client's stool: This suggests steatorrhea, commonly linked to malabsorption syndromes—not relevant to recent thrombolytic use or bleeding risk. B. Obtain a specimen for culture and sensitivity analysis: This is used to identify infectious organisms in cases of suspected gastrointestinal infection, not bleeding, which is the primary concern post-thrombolytic therapy. C. Send a stool sample to the lab for a guaiac test: A guaiac test detects occult (hidden) blood in stool, which is essential for identifying gastrointestinal bleeding—a major complication of thrombolytic therapy. D. Observe the stool for a clay-colored appearance: Clay-colored stool may indicate biliary obstruction or liver dysfunction, not a bleeding issue, which is the critical concern after thrombolytic administration.