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 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.

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.

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.

Choice D reason: Pacemaker placement is not relevant to managing stridor. Pacemakers are used for cardiac rhythm management and do not address airway obstruction.

A. Replace dietary table salt with salt substitutes. B. Encourage active range of motion to limit stiffness. C. Take prescribed pain medication after exercising joints. D. Avoid the consumption of wine, beer, and coffee.

Correct Answer is D

Explanation

Choice A reason: Replacing dietary table salt with salt substitutes is not specifically related to managing gout. Gout is caused by the accumulation of uric acid crystals in the joints, leading to inflammation and pain. The primary dietary factor influencing gout is purine intake, not sodium. While reducing sodium intake is generally beneficial for overall cardiovascular health, it does not directly impact uric acid levels or the management of gout. Therefore, recommending salt substitutes does not address the underlying cause or prevention of gout attacks. Moreover, some salt substitutes contain potassium chloride, which can have its own health implications, particularly for individuals with kidney issues.

Choice B reason: Encouraging active range of motion to limit stiffness is important for maintaining joint function in many conditions, but during an acute gout attack, the primary focus should be on reducing inflammation and pain. Gout attacks cause severe pain and swelling, particularly in the affected joint, and encouraging active movement during an acute phase can exacerbate the pain and inflammation. It is more appropriate to rest the affected joint and manage pain and inflammation with medications and other supportive measures. Once the acute phase has resolved, gradual reintroduction of movement and exercise can help maintain joint function and prevent long-term stiffness.

Choice C reason: Taking prescribed pain medication after exercising joints is not appropriate advice for managing gout. Pain medication, such as NSAIDs (nonsteroidal anti-inflammatory drugs), should be taken as prescribed by the healthcare provider to effectively manage pain and inflammation. It is crucial to follow the prescribed regimen for pain management, regardless of exercise or activity. Furthermore, during an acute gout attack, it is advisable to avoid activities that may aggravate the affected joint. Pain management should be proactive, and medications should be taken at regular intervals to maintain pain relief rather than in response to specific activities like exercise.

Choice D reason: Avoiding the consumption of wine, beer, and coffee is crucial for managing gout. Alcohol, particularly beer and wine, contains high levels of purines, which can increase uric acid production and exacerbate gout symptoms. Alcohol also promotes dehydration, which can lead to higher uric acid concentrations in the blood. Both of these factors can trigger gout attacks. Coffee has mixed effects on gout; while some studies suggest that moderate coffee consumption may not significantly impact uric acid levels, it is generally advised to be cautious with its intake. Educating the client to avoid or limit these beverages can help prevent future gout attacks and manage symptoms more effectively. Dietary modifications are a key component of gout management, and avoiding high-purine foods and beverages is essential in reducing the frequency and severity of gout attacks.

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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

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

A client who is experiencing a first gouty arthritis attack reports excruciating pain in the right great toe. The nurse inspects the inflamed joint and administers ibuprofen 800mg PO as prescribed. Which instruction should the nurse include in the discharge teaching?

Correct Answer is D

Explanation

A client with oral cancer is receiving radiotherapy (RT) prior to surgery. Which intervention should the nurse teach the client to implement in managing mucositis related to RT?

A nurse is caring for a client with acute kidney injury (AKI). Which assessment finding warrants immediate intervention?

Four days following an abdominal aortic aneurysm repair, the client is exhibiting edema of both lower extremities, and pedal pulses are not palpable. Which action should the nurse implement first?

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A client who was recently diagnosed with Raynaud's disease is concerned about pain management. Which nursing instruction should the nurse provide?