Which nursing problem should be selected for a client who is receiving thrombolytic infusions for treatment of an acute myocardial infarction (AMI)?
Ineffective breathing pattern related to adverse drug effects.
Deficient knowledge related to a new medication regimen.
Risk for injury related to effects of thrombolytics.
Activity intolerance related to ischemia.
The Correct Answer is C
Choice A reason: While thrombolytics can have respiratory side effects, they are not the primary concern.
Choice B reason: While patient education is important, the immediate risk for injury due to the effects of thrombolytics is more critical.
Choice C reason:
The correct answer is c) because thrombolytics can increase the risk of bleeding and other complications, making injury prevention a priority.
Choice D reason: Activity intolerance is important but not as immediate as the risk for injury from thrombolytic therapy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Measuring intake and output is important but not the immediate action needed to address blood clots.
Choice B reason:
The correct answer is b) because increasing the flow of the bladder irrigation can help to flush out blood clots and maintain catheter patency.
Choice C reason: Providing additional oral fluid intake is helpful but not the initial action to clear clots.
Choice D reason: Administering an antispasmodic agent can relieve bladder spasms but does not address the clots directly.
Correct Answer is A
Explanation
Choice A reason:
The correct answer is a) because a serum sodium level of 185 mEq/L is significantly higher than the normal range (136 to 145 mEq/L) and indicates severe hypernatremia, which requires immediate intervention to prevent complications such as neurological damage.
Choice B reason: Polyuria and excessive thirst are common symptoms of diabetes insipidus and require attention but are not as immediately critical as severe hypernatremia.
Choice C reason: Dry skin with inelastic turgor indicates dehydration, which is a concern, but immediate intervention is more critical for a significantly elevated serum sodium level.
Choice D reason: An apical heart rate of 110 beats per minute is elevated but does not require as immediate intervention as severe hypernatremia.
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