A client received a thrombolytic medication following a myocardial infarction. When the client has a bowel movement, which action should the nurse implement?

Assess for fatty yellow streaks in the client's stool.

Obtain a specimen for culture and sensitivity analysis.

Send a stool sample to the lab for a guaiac test.

Observe the stool for a clay-colored appearance.

Answer and Explanation

The Correct Answer is C

Rationale:

A. Assess for fatty yellow streaks in the client's stool: This suggests steatorrhea, commonly linked to malabsorption syndromes—not relevant to recent thrombolytic use or bleeding risk.

B. Obtain a specimen for culture and sensitivity analysis: This is used to identify infectious organisms in cases of suspected gastrointestinal infection, not bleeding, which is the primary concern post-thrombolytic therapy.

C. Send a stool sample to the lab for a guaiac test: A guaiac test detects occult (hidden) blood in stool, which is essential for identifying gastrointestinal bleeding—a major complication of thrombolytic therapy.

D. Observe the stool for a clay-colored appearance: Clay-colored stool may indicate biliary obstruction or liver dysfunction, not a bleeding issue, which is the critical concern after thrombolytic administration.

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Correct Answer is D

Explanation

Rationale:

A. Monitoring effects of oxytocin administration to help achieve cervical dilation: This is appropriate during the first stage of labor. The second stage begins after full dilation, so oxytocin’s role in cervical change is no longer relevant at this point.

B. Assessing the fetal heart rate and pattern for signs of fetal distress: FHR monitoring is important throughout labor, including the second stage, but it is not unique to this phase. It supports safe delivery but does not directly facilitate the main goal of this stage—fetal expulsion.

C. Providing pain medication to increase the client's tolerance of labor pains: Pain management is crucial, but narcotics are typically avoided in the second stage due to potential neonatal respiratory depression. Also, this does not address the primary task of this stage.

D. Assisting the client to push effectively so that expulsion of the fetus can be achieved:
This is the hallmark intervention of the second stage of labor, where full dilation has occurred and the goal is delivery of the baby. Supporting effective pushing directly aids in achieving this outcome.

A. Encourage the client to obtain a complete physical exam, since these symptoms are consistent with an ulcer. B. Advise the client that he needs to seek immediate medical evaluation and treatment of these symptoms. C. Assure the client that his symptoms may only reflect reflux, since ulcer pain is not relieved with food. D. Instruct the client that these mild symptoms can generally be controlled with changes in his diet.

Correct Answer is A

Explanation

Rationale:

A. Encourage the client to obtain a complete physical exam, since these symptoms are consistent with an ulcer: The client’s symptoms are typical of a duodenal ulcer. A full evaluation allows for appropriate diagnosis and treatment without causing alarm.

B. Advise the client that he needs to seek immediate medical evaluation and treatment of these symptoms: Immediate evaluation is not warranted unless the client has signs of bleeding, perforation, or severe distress. A timely but routine follow-up is appropriate for stable symptoms.

C. Assure the client that his symptoms may only reflect reflux, since ulcer pain is not relieved with food: Duodenal ulcer pain is classically relieved by eating, while gastric ulcer pain may worsen with food. Dismissing the symptoms as reflux could delay interventions.

D. Instruct the client that these mild symptoms can generally be controlled with changes in his diet: While diet can influence ulcer symptoms, assuming dietary change alone is sufficient may delay proper medical evaluation and necessary pharmacologic treatment.

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A client received a thrombolytic medication following a myocardial infarction. When the client has a bowel movement, which action should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which nursing intervention is indicated for the second stage of labor?

Correct Answer is D

Explanation

A client shares with the nurse concerns of a possible stomach ulcer. The client is experiencing heartburn and a dull gnawing pain that is relieved with eating. Which is the best response by the nurse?

Correct Answer is A

Explanation

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