The nurse is caring for a client receiving thrombolytic therapy following an acute myocardial infarction (MI). Which nursing problem should the nurse identify as priority for this client?

Risk for injury related to effects of thrombolysis.

Activity intolerance related to ischemia.

Ineffective breathing pattern related to adverse drug effects.

Deficient knowledge related to a new medication regimen.

Answer and Explanation

The Correct Answer is A

A. Clients receiving thrombolytic therapy are at an increased risk of bleeding, which can manifest as internal bleeding, hemorrhage at vascular access sites, gastrointestinal bleeding, or intracranial bleeding. The nurse's priority is to 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.
B. While activity intolerance is a common nursing diagnosis for clients following an acute myocardial infarction due to myocardial ischemia, it is not the priority in this case where the client is actively receiving thrombolytic therapy.
C. While respiratory complications can occur following thrombolytic therapy, such as pulmonary embolism or bleeding into the lungs, the risk of bleeding complications takes precedence as the priority nursing problem for this client.
D. Education about the 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.

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Correct Answer is C

Explanation

C. An ANC of 500/mm3 (0.5 x 10/L) is indicative of severe neutropenia, which places the client at a significantly increased risk of developing infections due to the decreased ability of the immune system to fight off pathogens. Placing the client in protective isolation is essential to minimize the risk of exposure to infectious agents that could lead to severe infections
A. While reviewing the need for pneumococcal vaccine is important for preventing infections in immunocompromised clients, it may not be the most immediate priority in this scenario.
B. Implementing bleeding precautions is relevant for clients with thrombocytopenia but is not the most critical intervention for a client with severe neutropenia.
D. Assessing vital signs every 4 hours is a routine nursing intervention, but it may not directly address the heightened risk of infection associated with severe neutropenia.

A. Hold the next dose of lactulose. B. Continue the prescribed dose of lactulose. C. Replace total volume voided with oral or IV fluids. D. Report the number of diarrhea stools to the healthcare provider (HCP).

Correct Answer is B

Explanation

B. Lactulose works by acidifying the colonic contents, which promotes the conversion of ammonia (NH3) to ammonium (NH4+). Ammonium is less readily absorbed from the colon into the bloodstream, reducing systemic ammonia levels. This action helps alleviate the neurotoxic effects of ammonia on the brain, thereby improving neurological symptoms associated with hepatic encephalopathy.
A. Lactulose is required in clients with hepatic encephalopathy to excrete ammonia lowering its levels in blood. Holding the lactulose dose is inappropriate as the client’s ammonia levels are still high
C. Rehydrating the clients to replace lost fluids in the loose stools is important but does not address
the client’s elevated ammonia levels which may be exacerbating the client’s encephalopathy.
D. Reporting the number of diarrhea stools to the healthcare provider is important for ongoing assessment and management of the client's condition. However, it does not address the clients high ammonia levels.

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The nurse is caring for a client receiving thrombolytic therapy following an acute myocardial infarction (MI). Which nursing problem should the nurse identify as priority for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client has an absolute neutrophil count (ANC) of 500/mm3 (0.5 x 10/L) after completing chemotherapy. Which intervention is most important for the nurse to implement? Reference Range: Neutrophils (ANC) [2.500 to 5,800/mm (2.5 to 5.8 x 10/L)]

Correct Answer is C

Explanation

Correct Answer is B

Explanation

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