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A client is diagnosed with an acute myocardial infarction and is receiving tissue plasminogen activator, alteplase (Activase, tPA). Which action is a priority nursing intervention?
- A. Monitor for renal failure.
- B. Monitor psychosocial status.
- C. Monitor for signs of bleeding.
- D. Have heparin sodium available.
Correct Answer: C
Rationale: The priority nursing intervention for a client receiving tissue plasminogen activator (alteplase) for an acute myocardial infarction is to monitor for signs of bleeding. Alteplase is a thrombolytic medication that can lead to hemorrhage as a complication. Therefore, closely monitoring the client for any signs of bleeding is essential to promptly address and manage this potential adverse effect.
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A client has been started on long-term therapy with rifampin (Rifadin). A nurse teaches the client that the medication:
- A. Should always be taken with food or antacids
- B. Should be double-dosed if one dose is forgotten
- C. Causes orange discoloration of sweat, tears, urine, and feces
- D. May not be discontinued independently if symptoms are gone in 3 months
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client with coronary artery disease complains of substernal chest pain. After checking the client's heart rate and blood pressure, a nurse administers nitroglycerin, 0.4 mg, sublingually. After 5 minutes, the client states, 'My chest still hurts.' Select the appropriate actions that the nurse should take.
- A. Call a code blue.
- B. Contact the registered nurse.
- C. Contact the client's family.
- D. Assess the client's pain level.
Correct Answer: B
Rationale: The correct action for the nurse to take in this situation is to contact the registered nurse. When a client with coronary artery disease experiences chest pain and does not achieve relief after the initial administration of nitroglycerin, it is crucial to inform the registered nurse promptly. Following the usual guideline for nitroglycerin administration, the nurse may administer a second tablet after assessing the client's pain level. The nurse should continue to assess the client's pain and monitor vital signs before each dose administration. Calling a code blue is not warranted at this point, as the client's condition does not indicate an immediate life-threatening emergency. Contacting the client's family is not necessary unless requested by the client.
A client who has been newly diagnosed with diabetes mellitus has been stabilized with daily insulin injections. Which information should the nurse teach when carrying out plans for discharge?
- A. Keep insulin vials refrigerated at all times.
- B. Rotate the insulin injection sites systematically.
- C. Increase the amount of insulin before unusual exercise.
- D. Monitor the urine acetone level to determine the insulin dosage.
Correct Answer: B
Rationale: When a client is stabilized with daily insulin injections, it is crucial to rotate the injection sites systematically. This practice helps prevent the development of lipodystrophy, which can affect insulin absorption and lead to inconsistent glucose control. Additionally, rotating sites minimizes discomfort and tissue damage, ensuring optimal insulin delivery and effectiveness.
A client who had a kidney transplant is receiving therapy with cyclosporine (Sandimmune). Which statement by the client indicates a need for further instruction?
- A. I need to obtain a yearly influenza vaccine.
- B. I need to have dental checkups every 3 months.
- C. I need to self-monitor my blood pressure at home.
- D. I need to call the health care provider (HCP) if my urine volume decreases or my urine becomes cloudy.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Cycloserine (Seromycin) is added to the medication regimen for a client with tuberculosis. Which of the following would the nurse include in the client-teaching plan regarding this medication?
- A. To take the medication after meals
- B. To return to the clinic weekly for serum drug-level testing
- C. To call the health care provider (HCP) if a skin rash occurs
- D. To restrict alcohol intake with this medication
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.