The nurse is caring for a client receiving thrombolytic therapy following an acute myocardial infarction (MI). Which nursing problem should the nurse identify as priority for this client?

Risk for injury related to effects of thrombolysis.

Activity intolerance related to ischemia.

Ineffective breathing pattern related to adverse drug effects.

Deficient knowledge related to a new medication regimen.

Answer and Explanation

The Correct Answer is A

A. Clients receiving thrombolytic therapy are at an increased risk of bleeding, which can manifest as internal bleeding, hemorrhage at vascular access sites, gastrointestinal bleeding, or intracranial bleeding. The nurse's priority is to 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.
B. While activity intolerance is a common nursing diagnosis for clients following an acute myocardial infarction due to myocardial ischemia, it is not the priority in this case where the client is actively receiving thrombolytic therapy.
C. While respiratory complications can occur following thrombolytic therapy, such as pulmonary embolism or bleeding into the lungs, the risk of bleeding complications takes precedence as the priority nursing problem for this client.
D. Education about the 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.

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

Explanation

A. Regular physical activity is a cornerstone of prediabetes management. Exercise helps improve insulin sensitivity, promotes weight loss, and reduces the risk of progression to type 2 diabetes.
C. Weight reduction is an essential component of prediabetes management, especially for individuals who are overweight or obese. Losing as little as 5-10% of body weight can significantly improve insulin sensitivity and reduce the risk of developing type 2 diabetes.
G. Nutrition education: Nutrition education is a crucial component of prediabetes management. Providing education on healthy eating habits, portion control, carbohydrate counting, and making nutritious food choices can empower individuals with prediabetes to make positive dietary changes that support blood sugar control and overall health.
B. Short-acting insulin is not typically used in the treatment of prediabetes. Insulin therapy is usually reserved for individuals with type 1 diabetes or advanced type 2 diabetes who cannot adequately control blood sugar levels with oral medications or lifestyle interventions.
D. While oral antidiabetic medications may be prescribed for individuals with type 2 diabetes, they are not typically used as first-line therapy for prediabetes. Lifestyle modifications, such as diet and exercise, are usually the primary approach for managing prediabetes.
E. Individuals with prediabetes should generally aim to moderate their carbohydrate intake, particularly refined carbohydrates and added sugars, to help improve blood sugar control and reduce the risk of developing type 2 diabetes.
F. Similar to short-acting insulin, long-acting insulin is not typically used in the treatment of prediabetes. Insulin therapy is generally reserved for individuals with type 1 diabetes or advanced type 2 diabetes who require insulin to control blood sugar levels.

A. Auscultate lungs for unequal breath sounds. B. Continue to monitor the drainage system. C. Lift and clear drainage from the chest tube. D. Inspect the tube insertion site for leaking.

Correct Answer is B

Explanation

B. Tidaling is an expected finding in a functioning chest drainage system and indicates proper drainage of air or fluid from the pleural space. Continuously monitoring the drainage system allows the nurse to assess the volume, color, and consistency of drainage.
A. Rising water levels during inspiration and falling during expiration are indicative of proper chest tube function, therefore, auscultation for breath sounds may not provide additional relevant information related to the functioning of the chest tube.
C. Performing this action unnecessarily may disrupt the functioning of the drainage system and should only be done if specifically instructed by the healthcare provider.
D. While it is important to monitor for leaks, the observation of tidaling in the water-seal chamber does not necessarily indicate a leak at the insertion site.

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The nurse is caring for a client receiving thrombolytic therapy following an acute myocardial infarction (MI). Which nursing problem should the nurse identify as priority for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Review Hand P and laboratory results Exhibits What item(s) should be included in the treatment regimen for this client? Select all that apply.

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

Explanation

Correct Answer is B

Explanation

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