Nokea
When administering a thrombolytic drug to the client experiencing a myocardial infarction (MI), the nurse explains that the purpose of the drug is to:
- A. Help keep him well hydrated.
- B. Dissolve clots that he may have.
- C. Prevent kidney failure.
- D. Treat potential cardiac arrhythmias.
Correct Answer: B
Rationale: Thrombolytic drugs dissolve clots in coronary arteries, restoring blood flow to the myocardium during an MI, reducing infarct size and improving outcomes.
You may also like to solve these questions
The nurse is tracking data on a group of clients with heart failure who have been discharged from the hospital and are being followed at a clinic. Which of the following data indicate that nursing interventions of monitoring and teaching have been effective?
- A. 90 percent of clients have not gained weight.
- B. 75 percent of the clients viewed the educational video.
- C. 80 percent of the clients reported that they are taking their medications.
- D. 5 percent of the clients required hospitalization in the last 90 days.
Correct Answer: A,C,D
Rationale: No weight gain (A), medication adherence (C), and low hospitalization rates (D) indicate effective management of heart failure through monitoring and teaching.
Nursing responsibilities for the client with a patient-controlled analgesia (PCA) system should include:
- A. Reassuring the client that pain will be relieved.
- B. Documenting the client's response to pain medication on a routine basis.
- C. Instructing the client to continue pressing the system's button whenever pain occurs.
- D. Titrating the client's pain medication until the client is free from pain.
Correct Answer: B
Rationale: Documenting the client's response to PCA is a key nursing responsibility to monitor efficacy and safety. Reassuring complete relief, instructing to press repeatedly, or titrating to pain-free status may be unrealistic or unsafe.
The risk for injury during an attack of Ménière'sdisease is high. The nurse should instruct the client to take which immediate action when experiencing vertigo?
- A. Place your head between your knees.
- B. Concentrate on rhythmic deep breathing.
- C. Close your eyes tightly.
- D. Assume a reclining or flat position.
Correct Answer: D
Rationale: Assuming a reclining or flat position during a vertigo attack minimizes the risk of falling and injury by stabilizing the client's position.
A nurse assesses a 40-year-old female client with vasospastic disorder (Raynaud’s phenomenon) involving her right hand. The nurse notes the information in the progress notes, as shown below. From these fi ndings, the nurse should formulate which priority nursing diagnosis?
- A. Acute pain related to hyperemic stage
- B. Disturbed sensory perception (tactile) related to vasospastic process.
- C. Ineffective tissue perfusion (peripheral) related to vasospastic process.
- D. Risk for impaired skin integrity related to vasospastic process.
Correct Answer: B
Rationale: The client complains of numbness in her fingertips, thus Disturbed sensory perception (tactile) is the priority nursing diagnosis. The client does not complain of acute pain. The other data suggest that the circulation is adequate at this time, so neither Ineffective tissue perfusion nor Risk for impaired skin integrity is the priority nursing diagnosis.
A 56-year-old client is receiving chemotherapy that has the potential to cause pulmonary toxicity. Which of the following symptoms indicates a toxic response to the chemotherapy?
- A. Decrease in appetite.
- B. Drowsiness.
- C. Spasms of the diaphragm.
- D. Cough and shortness of breath.
Correct Answer: D
Rationale: Cough and shortness of breath are hallmark symptoms of pulmonary toxicity, indicating potential lung damage from chemotherapy and requiring immediate attention.