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.

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Correct Answer is B

Explanation

Choice A reason: Massage therapy can help with relaxation and improving circulation in some cases, but it is not a primary intervention for managing PAD. Structured exercise is more effective in improving symptoms and overall cardiovascular health.

Choice B reason: Structured exercise is the most appropriate intervention for a client with PAD. Regular physical activity, especially walking, can help improve blood flow, reduce symptoms, and enhance overall cardiovascular health. It is recommended that clients with PAD engage in a supervised exercise program to ensure safety and effectiveness.

Choice C reason: A carnivore diet is not recommended for clients with PAD. A heart-healthy diet that includes a variety of fruits, vegetables, whole grains, lean proteins, and healthy fats is more beneficial for managing PAD and reducing cardiovascular risk factors.

Choice D reason: Leg elevation can help reduce swelling and improve comfort, but it is not a primary intervention for managing PAD. Structured exercise has a more significant impact on improving blood flow and reducing symptoms.

A. Central line insertion. B. Nasogastric tube (NGT) insertion. C. Tracheostomy placement. D. Pacemaker placement.

Correct Answer is C

Explanation

Choice A reason: Central line insertion is not the appropriate intervention for managing stridor in a postoperative parathyroidectomy patient. Stridor indicates airway obstruction, which requires immediate airway management, not central venous access. Inserting a central line would not address the underlying issue of compromised airway patency, and it would delay necessary interventions to secure the airway.

Choice B reason: Nasogastric tube (NGT) insertion is not the correct intervention for stridor. NGT insertion is typically used for gastrointestinal decompression or feeding, not for managing airway obstruction. In the context of a client experiencing stridor, the priority is to ensure a patent airway, not to manage gastrointestinal issues. NGT insertion could potentially exacerbate airway compromise in a client with stridor.

Choice C reason: Tracheostomy placement is the correct intervention for managing stridor in a postoperative parathyroidectomy patient. Stridor indicates a potential airway obstruction, which can be life-threatening. A tracheostomy provides a secure airway and ensures adequate ventilation. This procedure is particularly important in cases where upper airway obstruction is suspected, such as swelling or hematoma formation following neck surgery.

Choice D reason: Pacemaker placement is not relevant to managing stridor. Pacemakers are used for cardiac rhythm management and do not address airway obstruction. The immediate concern for a client with stridor is ensuring a patent airway, and pacemaker placement would not resolve the airway compromise.

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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 nurse is developing home care instructions for a client with peripheral artery disease (PAD). Which intervention should the nurse include?

Correct Answer is B

Explanation

The nurse is assessing a client who is one day postoperative parathyroidectomy and finds that the client is experiencing stridor. After notifying the healthcare provider (HCP), the nurse should prepare for which procedure?

Correct Answer is C

Explanation

Exhibits The nurse has implemented additional needed actions. Indicate the assessment data which indicate the interventions were successful and which assessment data provide no indication that the interventions were successful. Each column must have at least one answer selected.

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