A client receiving thrombolytic infusions for treatment of an acute myocardial infarction (AMI) has which nursing problem?

Activity intolerance related to ischemia.

Risk for injury related to effects of thrombolytics.

Ineffective breathing pattern related to adverse drug effects.

Deficient knowledge related to a new medication regimen.

Answer and Explanation

The Correct Answer is B

Choice A reason: Activity intolerance related to ischemia is a common concern for clients with AMI, but it is not the primary nursing problem when the client is receiving thrombolytic therapy. The focus should be on monitoring for complications related to the therapy itself.

Choice B reason: Risk for injury related to effects of thrombolytics is the priority nursing problem for a client receiving thrombolytic therapy. Thrombolytics can cause serious bleeding complications, including internal bleeding, hemorrhage at vascular access sites, gastrointestinal bleeding, or intracranial bleeding. The nurse must closely monitor the client for signs and symptoms of bleeding, such as sudden onset or worsening of headache, changes in level of consciousness, hematuria, melena, ecchymosis, or hematoma formation.

Choice C reason: Ineffective breathing pattern related to adverse drug effects can occur following thrombolytic therapy, but it is not the primary concern. The risk of bleeding complications takes precedence as the priority nursing problem for this client.

Choice D reason: Deficient knowledge related to a new medication regimen is important for client understanding and adherence, but it is not the priority nursing problem in the immediate post-thrombolytic therapy period. Ensuring the client's safety by monitoring for bleeding complications is the primary focus.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A reason: An exit site infection can occur around the catheter insertion site, leading to redness, tenderness, and drainage. While this is a concerning issue that needs to be addressed, the more significant complication to prevent is peritonitis, which can result from an exit site infection if it spreads.

Choice B reason: Peritonitis is a serious and potentially life-threatening infection of the peritoneal cavity. In clients on peritoneal dialysis, signs such as redness, tenderness, and drainage around the catheter site are alarming indicators that could lead to peritonitis if not promptly treated. Peritonitis can cause severe abdominal pain, fever, and cloudy dialysis fluid, and requires immediate medical intervention to prevent complications.

Choice C reason: Outflow obstruction is a complication where the peritoneal dialysis fluid does not drain properly. This can be caused by a number of issues including catheter malposition or blockages, but it is not directly related to the symptoms of redness, tenderness, and drainage at the catheter site. Outflow obstruction is important to monitor but does not represent the immediate risk that peritonitis does.

Choice D reason: Atelectasis refers to the collapse of a part or all of a lung, often due to blockage of the air passages. This is not related to the symptoms around the peritoneal dialysis catheter site. While respiratory issues must be monitored, the primary concern here is the potential for peritoneal infection.

A. Jugular vein distension B. Lower extremity edema C. Hepatomegaly D. Fatigue

Correct Answer is B

Explanation

Choice A reason: Jugular vein distension is often associated with right-sided heart failure, where the right ventricle fails to pump effectively, leading to increased pressure in the veins and fluid backup. While it can occur in advanced cases of left ventricular dysfunction, it is not as directly indicative as lower extremity edema.

Choice B reason: Lower extremity edema is a common finding in left ventricular dysfunction. When the left ventricle fails to pump blood efficiently, it leads to a buildup of fluid in the lungs and eventually in the extremities. This results in swelling, particularly in the lower legs and feet. This symptom is a key indicator of congestive heart failure.

Choice C reason: Hepatomegaly, or enlargement of the liver, is more commonly associated with right-sided heart failure due to congestion of blood flow in the liver. While it can occur in severe cases of left ventricular dysfunction, it is not as typical an initial finding as lower extremity edema.

Choice D reason: Fatigue is a non-specific symptom that can be associated with various conditions, including heart failure. However, it is not as immediately indicative of left ventricular dysfunction as lower extremity edema, which is more directly related to the underlying issue of fluid retention and heart failure.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A client receiving thrombolytic infusions for treatment of an acute myocardial infarction (AMI) has which nursing problem?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with chronic kidney disease on peritoneal dialysis exhibits redness, tenderness, and drainage around the catheter site on the abdominal wall. While planning care, the nurse is most concerned about preventing which complication related to these findings?

Correct Answer is B

Explanation

An adult client newly diagnosed with left ventricular dysfunction is admitted to the hospital with fine rales and wheezing. When assessing this client, which additional finding is the nurse likely to obtain?

Correct Answer is B

Explanation

A client who suffered an electrical injury with the entrance site on the left hand and the exit site on the left foot is admitted to the burn unit. Which intervention is most important for the nurse to include in this client’s plan of care?

Exhibits The nurse is stabilizing the client and preparing her for surgery. Which goals should the nurse prioritize in the plan of care for the client while in the emergency department (ED)? Select all that apply.

The nurse has conducted a cancer prevention community education program. In evaluating the participants' understanding of the carcinogens, which statement indicates an accurate understanding?

When teaching a client with Parkinson's disease, which rationale for the prescription of carbidopa-levodopa should the nurse include?

A client with rheumatoid arthritis has an elevated serum rheumatoid factor. Which interpretation of this finding should the nurse make?