Nokea
Which nursing interventions should the nurse implement for the client diagnosed with a pulmonary embolus who is undergoing thrombolytic therapy? Select all that apply.
- A. Keep protamine sulfate readily available.
- B. Avoid applying pressure to venipuncture sites.
- C. Assess for overt and covert signs of bleeding.
- D. Avoid invasive procedures and injections.
- E. Administer stool softeners as ordered.
Correct Answer: B,C,D
Rationale: Avoiding pressure (B), monitoring bleeding (C), and avoiding procedures (D) prevent hemorrhage during thrombolytics. Protamine (A) reverses heparin, and softeners (E) are unrelated.
You may also like to solve these questions
Your patient, who is receiving Pyrazinamide, report stiffness and extreme pain in the right big toe. The site is extremely red, swollen, and warm. You notify the physician and as the nurse you anticipated the doctor will order?
- A. Calcium level
- B. Vitamin B6 level
- C. Uric acid level
- D. Amylase level
Correct Answer: C
Rationale: Pyrazinamide can cause hyperuricemia, leading to gout symptoms (pain, redness, swelling in joints like the big toe). The physician will likely order a uric acid level to confirm this side effect.
Which finding best indicates that the sponge bath is having a therapeutic effect on the client?
- A. The client feels more comfortable.
- B. The client begins sweating profusely.
- C. The client's temperature is 101°F (38.3°C).
- D. The client's skin is flushed.
Correct Answer: C
Rationale: A reduced temperature (101°F) directly indicates the sponge bath is effectively lowering the client's fever.
A 72 year-old male patient who is diagnosed with bilateral lower lobe pneumonia is admitted to your unit. The patient has a history of systolic heart failure and arthritis. On assessment, you note the patient has a respiratory rate of 21 , oxygen saturation $93 \%$ on $2 \mathrm{~L}$ nasal cannula, is alert & oriented, and has a productive cough with green/yellowish sputum. Which of the following nursing interventions will you provide to this patient based on your assessment findings and the patient's diagnosis? Select-all-that-apply:
- A. Keep head-of-the-bed less than 30 degrees at all times.
- B. Collect sputum cultures.
- C. Encourage 3L of fluids a day to keep secretions thin.
- D. Encourage incentive spirometer usage
- E. Provide education about receiving the Pneumovax vaccine annually.
Correct Answer: B,D
Rationale: Sputum cultures identify the causative organism, and incentive spirometer use promotes lung expansion. Head-of-bed <30 degrees increases aspiration risk, 3L fluids may overload heart failure patients, and Pneumovax is not annual.
If the client complains of GI side effects associated with rifampin (Rifadin), which nursing action is best?
- A. Administering the drug at night
- B. Giving the drug with food or at mealtimes
- C. Encouraging the client to drink plenty of water
- D. Providing the client with an antacid
Correct Answer: B
Rationale: Giving rifampin with food can reduce gastrointestinal side effects, such as nausea, without compromising its efficacy.
While the nurse is suctioning a tracheostomy tube, the client starts to cough. What is the best action for the nurse to take?
- A. Suction deeper to pick up secretions
- B. Gently withdraw suction tubing to allow suction or coughing out of mucus
- C. Remove the suction as quickly as possible
- D. Put the suction tube in and out several times to pick up secretions
Correct Answer: C
Rationale: Removing the suction quickly allows the client to cough out mucus naturally, preventing irritation or trauma.