Nokea
A client has acute arterial occlusion. The physician has ordered a thrombolytic agent. Before starting the medication, the nurse should:
- A. Review the blood coagulation laboratory values
- B. Test the client's stools for occult blood
- C. Count the client's apical pulse for 1 minute
- D. Check the 24-hour urine output record
Correct Answer: A
Rationale: Before administering a thrombolytic agent for acute arterial occlusion, the nurse must review coagulation lab values (e.g., aPTT, INR, platelets) to assess bleeding risk, as thrombolytics increase hemorrhage potential. Stool testing, pulse counting, and urine output are secondary or unrelated.
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The nurse notes a client's preoperative hemoglobin is 9.8 g/dL. What is the priority nursing action?
- A. Administer iron supplements as ordered.
- B. Notify the surgeon of the result.
- C. Encourage a high-protein diet.
- D. Document the finding and continue preparations.
Correct Answer: B
Rationale: A hemoglobin of 9.8 g/dL indicates anemia, which increases surgical risks. Notifying the surgeon ensures evaluation and possible intervention before proceeding.
A client with Parkinson's disease needs a long time to complete her morning hygiene, but she becomes annoyed when the nurse offers assistance and refuses all help. Which action is the nurse's best initial response in this situation?
- A. Tell the client firmly that she needs assistance and help her with her care.
- B. Praise the client for her desire to be independent and give her extra time and encouragement.
- C. Tell the client that she is being unrealistic about her abilities and must accept the fact that she needs help.
- D. Suggest to the client that if she insists on self-care, she should at least modify her routine.
Correct Answer: B
Rationale: Praising independence and providing extra time respects the client's autonomy while supporting her efforts. Forcing help, labeling her unrealistic, or suggesting modifications may undermine her dignity.
Following a transsphenoidal hypophysectomy, the nurse should assess the client for:
- A. Cerebrospinal fluid (CSF) leak.
- B. Fluctuating blood glucose levels.
- C. Cushing's syndrome.
- D. Cardiac arrhythmias.
Correct Answer: A
Rationale: A CSF leak is a potential complication of transsphenoidal hypophysectomy due to the surgical approach through the sphenoid sinus, requiring careful monitoring.
A client receives a thrombolytic agent. The expected outcome of this drug therapy includes:
- A. Improved cerebral perfusion
- B. Decreased vascular permeability
- C. Dissolved emboli
- D. Prevention of further cerebral hemorrhage
Correct Answer: C
Rationale: Thrombolytic agents (e.g., alteplase) dissolve existing clots, such as emboli in pulmonary embolism or arterial occlusion, restoring blood flow. They do not improve cerebral perfusion, decrease vascular permeability, or prevent cerebral hemorrhage (they increase bleeding risk).
The nurse should teach the client with diverticulitis to integrate which of the following into a daily routine at home?
- A. Using enemas to relieve constipation.
- B. Decreasing fluid intake to increase the formed consistency of the stool.
- C. Eating a high-fiber diet when symptomatic with diverticulitis.
- D. Refraining from straining and lifting activities.
Correct Answer: D
Rationale: Refraining from straining and lifting activities prevents increased intra-abdominal pressure, reducing the risk of diverticulitis complications. Enemas, decreased fluid, or high-fiber diets during acute symptoms can worsen the condition. CN: Physiological adaptation; CL: Synthesize