Nokea
Which symptom would the nurse expect to observe if the client is having an allergic reaction to streptokinase (Streptase)?
- A. Urticaria
- B. Anuria
- C. Hemoptysis
- D. Dyspepsia
Correct Answer: A
Rationale: Urticaria (hives) is a common sign of an allergic reaction to streptokinase, a thrombolytic agent.
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The telemetry nurse notes a peaked T wave for the client diagnosed with congestive heart failure. Which laboratory data should the nurse assess?
- A. CK-MB.
- B. Troponin.
- C. BNP.
- D. Potassium.
Correct Answer: D
Rationale: Peaked T waves indicate hyperkalemia; assessing potassium (D) is critical in CHF patients on diuretics. CK-MB (A) and troponin (B) are for MI, BNP (C) for heart failure severity.
The client who is one (1) day postoperative coronary artery bypass surgery is exhibiting sinus tachycardia. Which intervention should the nurse implement?
- A. Assess the apical heart rate for one (1) full minute.
- B. Notify the client's cardiac surgeon.
- C. Prepare the client for synchronized cardioversion.
- D. Determine if the client is having pain.
Correct Answer: D
Rationale: Sinus tachycardia post-CABG is often due to pain (D), which should be assessed first. Heart rate (A), notifying (B), and cardioversion (C) follow if needed.
Which assessment finding documented by the nurse provides the best evidence that the client has a bacterial infection?
- A. Chest pain
- B. Dry cough
- C. Fever
- D. Dyspnea
Correct Answer: C
Rationale: Fever is a hallmark of bacterial infection, such as in endocarditis.
The nurse has received shift report. Which client should the nurse assess first?
- A. The client diagnosed with coronary artery disease complaining of severe indigestion.
- B. The client diagnosed with congestive heart failure who has 3+ pitting edema.
- C. The client diagnosed with atrial fibrillation whose apical rate is 110 and irregular.
- D. The client diagnosed with sinus bradycardia who is complaining of being constipated.
Correct Answer: A
Rationale: Severe indigestion in CAD (A) may indicate angina or MI, requiring immediate assessment. Edema (B), tachycardia (C), and constipation (D) are less urgent.
An adult has a coagulation time of 20 minutes. The nurse should observe the client for which of the following?
- A. Blood clots
- B. Ecchymotic areas
- C. Jaundice
- D. Infection
Correct Answer: B
Rationale: The normal clotting time is 9 to 12 minutes. A prolonged clotting time suggests a bleeding tendency, so the client should be observed for signs of bleeding, such as ecchymotic areas. Blood clots would occur with a shorter clotting time. Jaundice is related to liver damage or red blood cell breakdown. Infection is associated with low white blood cell counts.