Nokea
A client in a health care facility is receiving the thrombolytic drug reteplase. Which nursing diagnosis would be most likely?
- A. Anxiety
- B. Constipation
- C. Disturbed Sensory Perception
- D. Ineffective Tissue Perfusion
Correct Answer: A
Rationale: The nursing diagnoses for a client receiving the thrombolytic drug reteplase should include Anxiety, as thrombolytic therapy can be stressful due to its critical nature.
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A client taking warfarin asks the nurse about using herbal remedies. Which of the following would the nurse instruct the client to avoid? Select all that apply.
- A. Chamomile
- B. St. Johns wort
- C. Ginkgo biloba
- D. Ginger
- E. Ginseng
Correct Answer: A,B,C,D,E
Rationale: Warfarin has the potential to interact with many herbal remedies, such as chamomile, St. John's wort, ginkgo biloba, ginger, and ginseng, which may increase the risk of bleeding.
A nurse is conducting an in-service presentation about hemostasis. The nurse determines that the teaching was successful when the class identifies a thrombus as which of the following?
- A. Damage to a blood vessel
- B. Formation of a blood clot
- C. Cessation of bleeding
- D. Coagulation cascade
Correct Answer: B
Rationale: A thrombus refers to the formation of a blood clot, sometimes from damage, in a vessel that impedes blood flow.
A client is being discharged from the hospital with a prescription for clopidogrel. The nurse would instruct the client about which of the following as a possible adverse reaction? Select all that apply.
- A. Skin rash
- B. Bleeding
- C. Heart palpitations
- D. Nausea
- E. Constipation
Correct Answer: A,B,C,E
Rationale: The most common adverse reactions associated with clopidogrel are skin rash, dizziness, bleeding, palpitations, and constipation.
A client is prescribed warfarin. The client also takes a diuretic for the treatment of cardiac problems. The nurse would anticipate which of the following?
- A. Decreased effectiveness of the anticoagulant
- B. Increased effectiveness of the diuretic
- C. Increased absorption of the anticoagulant
- D. Increased absorption of the diuretic
Correct Answer: A
Rationale: The nurse should monitor for decreased effectiveness of warfarin as an effect of the interaction between the anticoagulant and the diuretic.
A client with intermittent claudication is prescribed cilostazol by the primary health care provider. The nurse would expect to administer this drug cautiously if the client's history reveals which of the following?
- A. Intermittent claudication
- B. Pulmonary emboli
- C. Myocardial infarction
- D. Pancytopenia
Correct Answer: D
Rationale: The nurse should administer cilostazol with caution to clients with pancytopenia. Anticoagulants are used for the prevention and treatment of pulmonary emboli, the adjuvant treatment of myocardial infarction, and the treatment of intermittent claudication.