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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A reason: Absence of bowel sounds can be expected postoperatively and is not as urgent as other signs.

Choice B reason:

The correct answer is b) because a purple stoma mucosa indicates compromised blood flow to the stoma, which requires immediate surgical intervention to prevent tissue necrosis.

Choice C reason: Streaks of bright red blood in the stoma are not unusual shortly after surgery and are not an immediate cause for alarm.

Choice D reason: Brown fecal matter with a solid consistency is a normal finding post-colostomy and does not need to be reported immediately.

A. Platelet count. B. Serum electrolytes. C. Complete blood count. D. Liver enzymes.

Correct Answer is C

Explanation

Choice A reason: Platelet count is important for assessing clotting status but is not directly related to iron deficiency anemia.

Choice B reason: Serum electrolytes are important for overall health but do not directly address iron deficiency anemia.

Choice C reason:

The correct answer is c) because a complete blood count (CBC) provides crucial information about hemoglobin and hematocrit levels, which are directly impacted by iron deficiency anemia. Reviewing the CBC can help determine the severity of anemia and guide further treatment.

Choice D reason: Liver enzymes are important for assessing liver function but are not directly related to iron deficiency anemia.

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Which nursing problem should be selected for a client who is receiving thrombolytic infusions for treatment of an acute myocardial infarction (AMI)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse assesses an adult client 24 hours after a bowel exploration and formation of a sigmoid colostomy. Which assessment finding should be reported to the surgeon immediately?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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