A client receiving thrombolytic infusions for treatment of an acute myocardial infarction (AMI) has which nursing problem?

Activity intolerance related to ischemia.

Risk for injury related to effects of thrombolytics.

Ineffective breathing pattern related to adverse drug effects.

Deficient knowledge related to a new medication regimen.

Answer and Explanation

The Correct Answer is B

Choice A reason: Activity intolerance related to ischemia is a common concern for clients with AMI, but it is not the primary nursing problem when the client is receiving thrombolytic therapy. The focus should be on monitoring for complications related to the therapy itself.

Choice B reason: Risk for injury related to effects of thrombolytics is the priority nursing problem for a client receiving thrombolytic therapy. Thrombolytics can cause serious bleeding complications, including internal bleeding, hemorrhage at vascular access sites, gastrointestinal bleeding, or intracranial bleeding. The nurse must closely monitor the client for signs and symptoms of bleeding, such as sudden onset or worsening of headache, changes in level of consciousness, hematuria, melena, ecchymosis, or hematoma formation.

Choice C reason: Ineffective breathing pattern related to adverse drug effects can occur following thrombolytic therapy, but it is not the primary concern. The risk of bleeding complications takes precedence as the priority nursing problem for this client.

Choice D reason: Deficient knowledge related to a new medication regimen is important for client understanding and adherence, but it is not the priority nursing problem in the immediate post-thrombolytic therapy period. Ensuring the client's safety by monitoring for bleeding complications is the primary focus.

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Correct Answer is ["A","B","C","D","G"]

Explanation

Choice A reason:

Infection prevention is crucial in managing appendicitis. Administering preoperative antibiotics, such as cefazolin, helps prevent surgical site infections and other complications. This aligns with standard care protocols for appendicitis patients.

Choice B reason:

Relieving acute pain is a priority in appendicitis care. Administering analgesics, including opioids, acetaminophen, and NSAIDs, effectively manages pain and reduces inflammation. Providing distraction techniques can also help alleviate discomfort until pain relief is achieved.

Choice C reason:

Client education about the diagnosis and plan of care is essential. Informing the patient about appendicitis, the surgical procedure, and postoperative expectations reduces anxiety and promotes cooperation. Effective communication enhances patient outcomes and satisfaction.

Choice D reason:

Effective coping with illness-related anxiety is important. Providing emotional support and addressing concerns can help the patient manage anxiety associated with the diagnosis and impending surgery. This approach contributes to overall well-being and recovery.

Choice G reason:

Fluid volume management is vital in appendicitis care. Administering intravenous fluids, such as Ringer's lactate, maintains hydration, supports renal function, and prepares the patient for surgery. Proper fluid balance is essential for optimal physiological function.

A. Distinguish the difference between herpes varicella and herpes zoster. B. Explain that the risk of developing shingles decreases with age. C. Affirm that a person with shingles has a history of chickenpox infection. D. Ask the client to describe the type of shingles that her brother has. E. Instruct client to report the development of fatigue and low-grade fever.

Correct Answer is ["A","C","E"]

Explanation

Choice A reason: Distinguishing the difference between herpes varicella and herpes zoster is important for client education. Herpes varicella (chickenpox) and herpes zoster (shingles) are caused by the same virus, the varicella-zoster virus (VZV). After a person recovers from chickenpox, the virus remains dormant in the nerve tissues and can reactivate years later as shingles. Educating the client about the relationship between these two conditions helps in understanding the risk and nature of shingles.

Choice B reason: Explaining that the risk of developing shingles decreases with age is incorrect. In fact, the risk of developing shingles increases with age, especially in individuals over 50. The immune system's ability to keep the varicella-zoster virus dormant decreases with age, leading to a higher likelihood of reactivation as shingles. Therefore, this choice is not appropriate for client education.

Choice C reason: Affirming that a person with shingles has a history of chickenpox infection is accurate. Shingles occurs when the dormant varicella-zoster virus reactivates in someone who has previously had chickenpox. This information helps the client understand the connection between past chickenpox infection and the potential for developing shingles.

Choice D reason: Asking the client to describe the type of shingles that her brother has is not relevant to the client's own risk or education about shingles. The focus should be on providing accurate information about shingles and its relation to chickenpox, not on the details of another person's condition.

Choice E reason: Instructing the client to report the development of fatigue and low-grade fever is important because these can be early symptoms of shingles. Early identification and treatment of shingles can help manage symptoms and reduce complications. Educating the client on what to watch for and when to seek medical attention is crucial for effective management.

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A client receiving thrombolytic infusions for treatment of an acute myocardial infarction (AMI) has which nursing problem?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits The nurse is stabilizing the client and preparing her for surgery. Which goals should the nurse prioritize in the plan of care for the client while in the emergency department (ED)? Select all that apply.

Correct Answer is ["A","B","C","D","G"]

Explanation

A client reports to the nurse of recently visiting someone who has a shingles infection. The client believes that having had chickenpox as a child will be protective against shingles. How should the nurse respond? Select all that apply.

Correct Answer is ["A","C","E"]

Explanation

The nurse observes an increased number of blood clots in the drainage tubing of a client with continuous bladder irrigation following a transurethral resection of the prostate (TURP). Which is the best initial nursing action?

A client with rheumatoid arthritis has an elevated serum rheumatoid factor. Which interpretation of this finding should the nurse make?

A client is recovering from the surgical removal of glass in the right eye. Which intervention should the nurse implement immediately following the procedure?

A client with diabetes mellitus is admitted with an upper respiratory infection. Which changes in blood glucose management should the nurse tell the client to expect?

A nurse is caring for a client with acute kidney injury (AKI). Which assessment finding warrants immediate intervention?

The nurse is assessing a client who is one day postoperative parathyroidectomy and finds that the client is experiencing stridor. After notifying the healthcare provider (HCP), the nurse should prepare for which procedure?