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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D","E"]
Explanation
Rationale:
A. Ask the client if someone brought her to the clinic: This may be useful in a general assessment but is not directly relevant to the client's urinary symptoms, bruising, or potential abuse concerns. It does not guide immediate care.
B. Review list of daily medications for aspirin or other anticoagulants: Ecchymoses may indicate increased bleeding risk, especially in older adults on aspirin or anticoagulants. Reviewing medications helps determine if bruising is medication-related or from trauma.
C. Question her if she previously or currently uses any illicit drugs: There’s no clinical indicator pointing toward drug use. This line of questioning may be inappropriate or unnecessary unless other findings support it.
D. Inquire if she is being emotionally or physically abused: Unexplained bruising, especially in older adults, can signal possible abuse. The nurse should screen for abuse sensitively and privately.
E. Determine number of sexual partners she has had recently: Given her report of sexual activity and urinary burning, assessing recent sexual history helps guide further STI screening and urinary symptom evaluation.
Correct Answer is ["A","C","E","G","H"]
Explanation
Rationale for Correct Choices:
- Blood pressure of 120/74 mm Hg: This is within the normal range and indicates stable cardiovascular function, which supports discharge readiness following an aortic aneurysm intervention.
- Pedal pulse of 2+ or better: A 2+ pulse signifies adequate peripheral perfusion. It is important for assessing vascular integrity postoperatively, especially for patients with a history of aneurysmal disease.
- Absence of numbness or tingling in feet: Normal neurovascular sensation in the lower extremities suggests intact peripheral nerve and vascular supply, a critical discharge criterion after vascular complications.
- Client has urine output of 1,600 mL in 24 hours: This volume reflects adequate renal perfusion and fluid balance, within the normal range (800-2000 mL/day for adults) both of which are necessary to confirm the kidneys are functioning properly post-recovery.
- Creatinine of 1.2 mg/dL (106 mmol/L): This value is within normal limits (0.6-1.2 mg/dL), indicating that renal function is preserved and not compromised by the previous cardiovascular event or interventions.
Rationale for Incorrect Choices:
- Capillary refill of 4 seconds in lower extremities: A capillary refill time longer than 2–3 seconds suggests impaired perfusion, which would warrant further evaluation before discharge.
- Pupils equal and nonresponsive to light: This indicates a serious neurological deficit, potentially related to brain injury or altered consciousness, and is incompatible with safe discharge.
- Skin that is pale, cool to touch: This suggests possible peripheral hypoperfusion or systemic circulatory compromise and would need to be resolved before considering discharge.
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