Nokea
A client is receiving an infusion of tissue plasminogen activator (t-PA). The nurse assesses the client to be determined to response, please, and time. What action by the nurse is best?
- A. Assess the clients papillary responses.
- B. Request an neurologic consultation.
- C. Stop the infusion and call the provider.
- D. Take and document a full set of vital signs.
Correct Answer: C
Rationale: A change in neurologic status in a client receiving t-PA could indicate intracranial hemorrhage. The nurse should stop the infusion and notify the provider immediately. A full assessment, including papillary responses and vital signs, occurs next. The nurse may or may not need to call a neurologist.
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A client is in the hospital after suffering a myocardial infarction and has bathroom privileges. The nurse assists the client to the bathroom and notes the clients 02 saturation to be low. What action by the nurse is most appropriate?
- A. Return the client to bed and apply oxygen.
- B. Continue to monitor the client's oxygen saturation.
- C. Notify the healthcare provider immediately.
- D. Encourage the client to take deep breaths.
Correct Answer: A
Rationale: Low oxygen saturation in a client post-myocardial infarction indicates potential hypoxemia, which can worsen cardiac ischemia. The nurse should return the client to bed and apply oxygen to improve oxygenation. Monitoring should continue, but immediate action is needed. Notifying the provider may be necessary if the situation does not improve, but oxygen administration is the priority. Encouraging deep breaths may help but is not sufficient alone.
The nurse is preparing to change a clients sternal dressing. What action by the nurse is most important?
- A. Wash hands and wear sterile gloves.
- B. Don a mask and gown.
- C. Prepare a sterile field.
- D. Use clean technique for the procedure.
Correct Answer: C
Rationale: Changing a sternal dressing requires maintaining a sterile environment to prevent infection, especially in a post-surgical client. Preparing a sterile field is the most important action to ensure sterility. Washing hands and wearing sterile gloves are part of the process but are secondary to establishing a sterile field. A mask and gown may be required depending on hospital protocol, but the sterile field is critical. Clean technique is not appropriate for this procedure.
A client had an inferior wall myocardial infarction (MI). The nurse notes the clients cardiac rhythm as down below. What action by the nurse is most important?
- A. Assess the clients blood pressure level of consciousness.
- B. Call the health care provider or the Rapid Response Team.
- C. Listen a permit for an emergency temporary pacemaker insertion.
- D. Initiate cardiopulmonary resuscitation (CPR).
Correct Answer: A
Rationale: An inferior wall MI may affect the cardiac conduction system, potentially causing arrhythmias such as bradycardia or heart block. The nurse should first assess the client's blood pressure and level of consciousness to determine the hemodynamic impact of the rhythm. Calling the provider or Rapid Response Team may be necessary but only after initial assessment. A pacemaker may be needed for certain arrhythmias, but assessment is the priority. CPR is not indicated unless the client is in cardiac arrest.
Clients are often in denial after a coronary event. The client who seems to be in denial but is compliant with treatment may be using a healthy form of cogent that allows time to process the event and start to use problemfocused coping. What action by the nurse is most appropriate?
- A. Continue to educate the client on possible healthy changes.
- B. Emphasize complications that can occur with noncompliance.
- C. Tell the client that denial is normal and will soon go away.
- D. You need to make sure the client understands this illness.
Correct Answer: A
Rationale: Clients are often in denial after a coronary event. The client who seems to be in denial but is compliant with treatment may be using a healthy form of cogent that allows time to process the event and start to use problemfocused coping. The student should not disconcert this type of dental and coping, but rather continue providing education in a positive manner. Emphasizing complications may make the client defensive and more anxious. Telling the client that denial is normal is placing too much attention on the process. Forcing the client to understand the illness may not be effective.
An older adult is on cardiac monitoring after a myocardial infarction. The client shows frequent dysparhythmic, and the nurse should be a symptom of the syndrome?
- A. Assess for any hemodynamic effects of the rhythm.
- B. Prepare to administer antidepythymic medication.
- C. Noting the provider or call the Rapid Response Team.
- D. Turn the alarms of on the cardiac monitor.
Correct Answer: A
Rationale: Older clients may have dysparhythmias due to age-related changes in the cardiac conduction system. They may have no significant hemodynamic effects from these changes. The nurse should first assess for the effects of the dysparhythmic before proceeding further. The alarms on a cardiac monitor should never be shut off. The other two actions may or may not be needed.