Nokea
Alteplase recombinant, or tissue plasminogen activator (t-PA), is administered during the first 6 hours after onset of myocardial infarction (MI) to:
- A. Control chest pain.
- B. Reduce coronary artery vasospasm.
- C. Control the arrhythmias associated with MI.
- D. Revascularize the blocked coronary artery.
Correct Answer: D
Rationale: t-PA dissolves clots in the coronary artery, restoring blood flow (revascularization) to the ischemic myocardium, critical within the first 6 hours of MI.
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What should the nurse do first for a client with a suspected spinal cord injury?
- A. Immobilize the spine.
- B. Administer pain medication.
- C. Check motor function.
- D. Obtain a CT scan.
Correct Answer: A
Rationale: Immobilizing the spine is the first priority to prevent further injury in a suspected spinal cord injury.
The nurse is teaching a client with a total knee replacement about incision care. Which statement by the client indicates a need for further teaching?
- A. I'll keep the incision clean and dry.'
- B. I'll report redness or drainage.'
- C. I'll change the dressing weekly.'
- D. I'll avoid soaking the incision.'
Correct Answer: C
Rationale: Changing the dressing weekly is too infrequent; daily or as-needed changes are required to monitor for infection.
A 45-year-old female client with breast cancer has completed chemotherapy and reports a decreased interest in sexual activity. The nurse should:
- A. Encourage her to discuss her feelings with her partner.
- B. Suggest she resume sexual activity to improve her mood.
- C. Refer her immediately to a sexual therapist.
- D. Advise her to wait until chemotherapy effects subside.
Correct Answer: A
Rationale: Encouraging open communication with her partner allows the client to address emotional and physical factors contributing to decreased sexual interest, fostering support and understanding.
A client is to receive peritoneal dialysis. To prepare for the procedure, the nurse should?
- A. Assess the dialysis access for a bruit and thrill.
- B. Insert an indwelling urinary catheter and drain all urine from the bladder.
- C. Ask the client to turn toward the left side.
- D. Warm the solution in the warmer.
Correct Answer: D
Rationale: Warming the dialysis solution prevents discomfort and promotes effective dialysis by relaxing abdominal muscles.
The nurse assesses the client's stoma during the initial postoperative period. Which of the following observations should be reported immediately to the physician?
- A. The stoma is slightly edematous.
- B. The stoma is dark red to purple.
- C. The stoma oozes a small amount of blood.
- D. The stoma does not expel stool.
Correct Answer: B
Rationale: A dark red to purple stoma indicates inadequate blood supply, which is a medical emergency requiring immediate reporting to the physician. Slight edema is expected post-surgery, a small amount of blood oozing is normal, and lack of stool expulsion in the initial period may not be immediately concerning unless other symptoms are present. CN: Physiological adaptation; CL: Analyze