Nokea
A client with acute myocardial infarction receives therapy with alteplase. Which finding indicates to the nurse that the client is experiencing a possible complication?
- A. Epistaxis
- B. Vomiting
- C. ECG changes
- D. Absent pedal pulses
Correct Answer: A
Rationale: Bleeding is an adverse effect of altepase therapy. The bleeding can be superficial or internal and can be spontaneous. None of the remaining options are side or adverse effects of altepase therapy.
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What condition should the nurse assess a client diagnosed with pernicious anemia for? Select all that apply.
- A. Weakness
- B. Constipation
- C. Shortness of breath
- D. Dusky lips and gums
- E. Smooth, sore, red tongue
Correct Answer: A,E
Rationale: Classic clinical indicators of pernicious anemia include weakness; mild diarrhea; and a smooth, sore, red tongue. The client may also have neurological findings, such as paresthesias, confusion, and difficulty with balance. Constipation is not a common finding with pernicious anemia. Pernicious anemia does not affect tissue oxygenation, so the mucous membranes do not become dusky, and the client does not exhibit shortness of breath.
When a client with alcohol dependency begins to talk about not having a problem with alcohol, the nurse should use which of the following approaches?
- A. Questioning the client about how much alcohol she drinks.
- B. Confronting the client with the fact that she was intoxicated 2 days ago.
- C. Pointing out how alcohol has gotten her into trouble.
- D. Listening to what the client states and then asking her how she plans to stay sober.
Correct Answer: D
Rationale: This approach uses therapeutic communication, acknowledging the client's perspective and encouraging problem-solving, which is effective for addressing denial in alcohol dependency.
A hospice nurse is caring for a client with breast cancer and brain metastasis. The nurse is reviewing the lab report below. According to the information in the chart, what should the nurse do next?
- A. Document these results on the medical record.
- B. Report the elevated potassium level immediately.
- C. Report the elevated calcium level immediately.
- D. Refrain from reporting the results because the client is in hospice care.
Correct Answer: C
Rationale: The normal calcium level is 9.0 to 10.5 mg/dL. Hypercalcemia is commonly seen with malignant disease and metastases. The other laboratory values are normal. Hypercalcemia can be treated with fluids, furosemide (Lasix), or administration of calcitonin. Failure to treat hypercalcemia can cause muscle weakness, changes in level of consciousness, nausea, vomiting, abdominal pain, and dehydration. Although the client is on hospice care, she will still need palliative treatment. Comfort and risk reduction are components of hospice care.
The nurse caring for a child diagnosed with leukemia notes that the platelet count is 20,000 mm3 (20 x 10^9/L). Based on this finding, the nurse should include which interventions in the plan of care? Select all that apply.
- A. Monitor stools for blood.
- B. Clean oral cavity with soft swabs.
- C. Provide appropriate play activities.
- D. Check the rectal temperature every 4 hours.
- E. Administer acetaminophen suppositories for fever.
Correct Answer: A,B,C
Rationale: A platelet count of 20,000 mm3 (20 x 10^9/L) places the child at risk for bleeding. The remaining options 1, 2, and 3 are accurate interventions. Taking rectal temperatures and the use of suppositories are avoided because of the risk of rectal bleeding.
Which of the following would be most important for the nurse to include in the teaching plan for a client who is taking phenelzine (Nardil)?
- A. Eating a normal amount of salt in the diet.
- B. Drinking 10 to 12 glasses of water each day.
- C. Allowing 10 days to achieve therapeutic effects.
- D. Avoiding foods high in tyramine.
Correct Answer: D
Rationale: Phenelzine, an MAOI, requires avoiding tyramine-rich foods to prevent hypertensive crisis.