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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Neutrophils are a type of white blood cell involved in the body's immune response, particularly in fighting bacterial infections. In the context of burns, especially full-thickness burns with purulent drainage, an elevated neutrophil count (neutrophilia) may indicate an ongoing infection. Burn wounds are susceptible to bacterial colonization and infection due to the loss of the skin's protective barrier.
B. Blood pH level refers to the acidity or alkalinity of the blood. While maintaining normal blood pH is crucial for overall health, changes in blood pH are not typically directly related to the presence of purulent drainage in burn wounds.
C. Serum albumin is a protein found in the blood that plays a role in maintaining osmotic pressure and transporting various substances, including drugs and hormones. Low serum albumin levels (hypoalbuminemia) can occur in individuals with severe burns due to increased protein loss through damaged skin and decreased protein synthesis. However, it is not directly related to evaluating purulent drainage from burn wounds.
D. Platelet count: Platelets are blood cells involved in clotting, which is essential for wound healing. While thrombocytopenia (low platelet count) can occur in individuals with severe burns,it is not directly related to assessing infection in burn wounds.
Correct Answer is C
Explanation
C. The client's symptoms of weakness and palpitations are suggestive of hypoglycemia, a common complication in individuals with diabetes, particularly those on glucose-lowering medications such as insulin or sulfonylureas. Excessive perspiration, also known as diaphoresis, is a classic symptom of hypoglycemia and indicates the body's response to low blood sugar levels.
A. Cold extremities can be a sign of poor peripheral circulation, which may occur in individuals with diabetes, particularly in advanced stages or in the presence of peripheral vascular disease. However, it is not as specific to the acute episode of hypoglycemia
B. Myalgia (muscle pain) in the wrists and hands is not a typical symptom of hypoglycemia.
D. Dark yellow urine may indicate dehydration, which can occur in individuals with poorly controlled diabetes or during episodes of hyperglycemia. While dehydration is a concern in diabetes management, it is not directly related to the acute episode of hypoglycemia.
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