Elsevier Adaptive Quizzing: Perfusion - Clotting
For which clinical indicator associated with a complication of portal hypertension would the nurse assess the client? 1. Liver abscess 2. Intestinal obstruction 3. Perforation of the duodenum 4. Hemorrhage from esophageal varices
Answer: 4. Hemorrhage from esophageal varices Rationale: The increased pressure within the portal circulatory system causes increased pressure in areas of portal systemic collateral circulation (most importantly, in the distal esophagus and proximal stomach). Hemorrhage is a possible complication. Liver abscesses may occur as a complication of intestinal infections, not portal hypertension. Intestinal obstruction may be caused by manipulation of the bowel during surgery, peritonitis, neurological disorders, or organic obstruction, not portal hypertension. Perforation of the duodenum usually is caused by peptic ulcers; it is not a direct result of portal hypertension or cirrhosis.
A client is admitted to the emergency department with crushing chest pain. A diagnosis of acute coronary syndrome is suspected. Which medication is indicated to prevent progression to a myocardial infarction? 1. Aspirin 2. Atropine 3. Gabapentin 4. Epinephrine
Answer: 1. Aspirin Rationale: Early administration of aspirin in the setting of acute myocardial infarction (MI) has been demonstrated to significantly reduce mortality. Aspirin inhibits the action of platelets, preventing their ability to clump together and form clots. The mechanism of acute coronary syndrome usually is ruptured plaque in one of the coronary arteries with clot formation obstruction blood flow. Prompt administration of an antiplatelet agent, such as aspirin, significantly reduces damage and can be lifesaving, the earlier the better; hence the reason why it is part of emergency management treatment. Gabapentin is an anticonvulsant and does not have a role in reducing development of an MI. Atropine and epinephrine are emergency medications that increase cardiac activity and thus oxygen demand; this can increase the risk for MI.
A client with which diagnosis will be at risk for development of a pulmonary embolism? 1. Atrial fibrillation 2. Forearm laceration 3. Migraine headache 4. Respiratory infection
Answer: 1. Atrial fibrillation Rationale: Inadequate atrial contraction that occurs during fibrillation leads to pooling of blood in both atria that may result in thrombus formation. Dislodgement of thrombus in the right atria will lead to pulmonary embolism, whereas dislodgement of thrombus in the left atria may lead to embolic stroke. A forearm laceration does not increase pulmonary embolism risk. Pulmonary embolism is not a complication of migraine headache. Respiratory infections do not increase pulmonary embolism risk.
A client on duloxetine therapy ingests ibuprofen for pain relief. Which adverse effect would the nurse anticipate with this combination of medications? 1. Bleeding 2. Hepatotoxicity 3. Serotonin syndrome 4. Cardiac dysrhythmias
Answer: 1. Bleeding Rationale: Duloxetine is a serotonin and norepinephrine reuptake inhibitor. When nonsteroidal anti-inflammatory drugs (such as aspirin) are consumed with duloxetine, a high risk of bleeding may result. Hepatotoxicity occurs due to the consumption of alcohol with duloxetine. Serotonin syndrome occurs when selective serotonin reuptake inhibitors are consumed along with duloxetine. Cardiac dysrhythmias may occur when sympathomimetics are taken with tricyclic antidepressants.
When caring for a client with diagnosis of right ventricular heart failure, the nurse expects which assessment findings? Select all that apply. One, some, or all responses may be correct. 1. Dependent edema 2. Swollen hands and fingers 3. Collapsed neck veins 4. Right upper quadrant discomfort 5. Oliguria
Answer: 1. Dependent edema 2. Swollen hands and fingers 4. Right upper quadrant discomfort Rationale: With right-sided heart failure, signs of systemic congestion occur as the right ventricle fails; key features include dependent edema and swollen hands and fingers. Upper right quadrant discomfort is expected with right ventricular failure because venous congestion in the systemic circulation results in hepatomegaly. Jugular venous collapse and oliguria are key features of left-sided heart failure. Left-sided heart failure is associated with decreased cardiac output.
A client with left ventricular heart failure and supraventricular tachycardia is prescribed digoxin 0.25 mg daily. Which changes would the nurse expect to find if this medication is therapeutically effective? Select all that apply. One, some, or all responses may be correct. 1. Diuresis 2. Tachycardia 3. Decreased edema 4. Decreased pulse rate 5. Reduced heart murmur 6. Jugular vein distention
Answer: 1. Diuresis 2. Tachycardia 3. Decreased edema Rationale: Digoxin increases kidney perfusion, which results in urine formation and diuresis. The urine output increases because of improved cardiac output and kidney perfusion, resulting in a reduction in edema. Because of digoxin's inotropic and chronotropic effects, the heart rate will decrease. Digoxin increases the force of contractions (inotropic effect) and decreases the heart rate (chronotropic effect). Digoxin does not affect a heart murmur. Jugular vein distention is a specific sign of right ventricular heart failure; it is treated with diuretics to reduce the intravascular volume and venous pressure.
At which site would the nurse expect to find internal bleeding when assessing a 10-year-old boy with hemophilia who has fallen while playing on the playground? 1. Joints 2. Abdomen 3. Cerebrum 4. Epiphyses
Answer: 1. Joints Rationale: Activity can result in bleeding in children with hemophilia; therefore weight-bearing joints, especially the knees, are the most common site of bleeding. The abdomen is usually protected from the trauma of direct force. The cerebrum is protected by the skull and is not likely to be injured. Bleeding from bones themselves is not common without other associated trauma.
A client who is receiving medication for an eye disorder reports bleeding in the eye. Which medication will the nurse expect to find in the client's recent medication history? 1. Ketorolac 2. Trifluridine 3. Natamycin 4. Ciprofloxacin
Answer: 1. Ketorolac Rationale: Ketorolac is a nonsteroidal anti-inflammatory medication that may disrupt platelet aggregation and can lead to bleeding in the eyes. Trifluridine is the topical antiviral agent that may cause sensitive reactions such as itching. Natamycin is an antifungal agent that may cause itching lids and burning eyes due to sensitivity. Ciprofloxacin is an anti-infective agent that may cause blindness if not taken in prescribed amounts.
A client sustains a crushing injury to the lower left leg, and a below-the-knee amputation is performed. For which common clinical manifestations of a pulmonary embolus would the nurse assess this client? Select all that apply. One, some, or all responses may be correct. 1. Sharp chest pain 2. Acute onset of dyspnea 3. Pain in the residual limb 4. Absence of the popliteal pulse 5. Blanching of the affected extremity
Answer: 1. Sharp chest pain 2. Acute onset of dyspnea Rationale: Emboli can occur with crushing injuries of the extremities. Lodging of a thrombus in the pulmonary system results in a lack of pulmonary tissues, causing localized sharp chest pain. Lodging of a thrombus in the pulmonary system will result in decreased breath sounds and dyspnea. Pain in the residual limb is related not to a pulmonary embolus but to severed nerve endings in the residual limb. A pulmonary embolus will not interfere with arterial circulation to a distal portion of an extremity. Blanching of the affected extremity is associated with interference with arterial circulation to an extremity.
A client is taking warfarin. If an antidote is needed, which agent will be used? 1. Vitamin K 2. Fibrinogen 3. Prothrombin 4. Protamine sulfate
Answer: 1. Vitamin K Rationale: Warfarin sodium inhibits vitamin K; therefore, vitamin K is the antidote for warfarin sodium. Fibrinogen and prothrombin are blood-clotting factors, not the antidotes for warfarin sodium. Protamine sulfate is the antidote for heparin, not warfarin sodium.
The registered nurse is evaluating the plans of a nursing student for providing preoperative care to a client who has compartment syndrome. Which item listed in the nursing student's plan of care would the nurse need to revise? Select all that apply. One, some, or all responses may be correct. 1. Bivalving the cast 2. Applying cold compresses 3. Loosening the bandage applied 4. Evaluating the client's level of pain 5. Elevating the extremity above heart level
Answer: 2. Applying cold compresses 5. Elevating the extremity above heart level Rationale: Compartment syndrome is a condition in which swelling and increased pressure within a limited space (a compartment) presses on and compromises the function of blood vessels, nerves, and tendons that run through that compartment. Applying cold compresses on the affect area results in vasoconstriction and worsens the condition. Elevating the extremity above the level of the heart may slow arterial perfusion. Bivalving the cast decreases pressure. Evaluating the client's level of pain is helpful to administer suitable medication. Loosening the bandage decreases pressure.
The prevent excessive bruising when administering subcutaneous heparin, which technique will the nurse employ? 1. Administer the injection via the Z-track technique. 2. Avoid massaging the injection site after the injection. 3. Use 2 mL of sterile normal saline to dilute the heparin. 4. Inject the medication into the vastus lateralis muscle in the thigh.
Answer: 2. Avoid massaging the injection site after the injection. Rationale: The site of the injection should not be massaged to avoid dispersion of the heparin around the site and subsequent bleeding into the area. The Z-track technique and the intramuscular route are not used with heparin; subcutaneous injection and intravenous administration are the routes appropriate for heparin administration. The medication should be injected into the subcutaneous tissue slowly, not quickly. Diluting heparin with normal saline is unnecessary. Generally, heparin is provided by the pharmacy department in single-dose syringes.
The nurse is caring for a client with biliary cancer. The associated jaundice gets progressively worse. The nurse is most concerned about the potential complication of which symptom? 1. Pruritus 2. Bleeding 3. Flatulence 4. Abdominal bloating
Answer: 2. Bleeding Rationale: Obstruction of bile flow impairs absorption of phytonadione, a fat-soluble vitamin; prothrombin is not produced, and the blotting process is prolonged. Although deposition of bile salts in the skin may lead to pruritus, this is not life threatening. Although there may be an increase in flatulence with biliary disease, it is not life threatening. Although abdominal bloating may occur with jaundice, it is not life threatening.
A client needs a continuous intravenous infusion of heparin at a rate of 1000 units per hour. There are 25,000 units of heparin in 500 mL of 5% dextrose solution. The nurse will set the infusion control device to deliver how many milliliters per hour? Record your answer using a whole number. ___ mL/h
Answer: 20 mL/h Rationale: The prescribed rate is 1000 u/h. The available concentration is 25,000 u in 500 mL D5W. Make the necessary conversions and use dimensional analysis to determine the appropriate rate in mL/h. The ratio and proportion method is not appropriate for this situation.
A client with known peripheral arterial disease calls the clinic and tells the nurse about experiencing several symptoms. Which symptom requires the most rapid action by the nurse? 1. Anxiety 2. Chest pain 3. Weak pulse quality 4. Cool and pale lower legs
Answer: 2. Chest pain Rationale: Because atherosclerosis is a systemic disease, clients with peripheral arterial disease are likely to have coronary artery disease as well. The client's chest pain may indicate acute coronary syndrome, and the nurse should notify the health care provider or have the client activate the emergency response system immediately. Anxiety can have many causes, and the nurse could further assess the client or assist the client to schedule an appointment. Weak pulse quality is expected with peripheral arterial disease; the client's disease may be progressing, but no rapid action is needed. Cool and pale lower extremities are expected with peripheral arterial disease; the client may need further evaluation for progression of disease but this not urgent.
The nurse is caring for a client in the postanesthesia care unit immediately after the client had a subtotal gastrectomy. The nurse identifies small blood clots in the client's gastric drainage. Which action would the nurse take? 1. Clamp the tube. 2. Consider this an expected event. 3. Instill the tube with iced normal saline. 4. Notify the health care provider immediately.
Answer: 2. Consider this an expected event. Rationale: Because of the trauma of surgery, some bleeding can be expected for 4 to 5 hours. Clamping the tube will cause increased pressure on the gastric sutures from a buildup of gas and fluid. Iced saline rarely is used because it causes vasoconstriction, local ischemia, and a reduction in body temperature. Notifying the client's surgeon of this finding is not necessary; this is an expected occurrence.
A client who is underweight has autoimmune hemolytic anemia that has been unresponsive to corticosteroids. A splenectomy is scheduled. For which complication would the nurse assess the client in the immediate postoperative period? 1. Dehiscence 2. Hemorrhage 3. Wound infection 4. Abscess formation
Answer: 2. Hemorrhage Rationale: A client is at risk for hemorrhage because of the vascularity of the spleen. Dehiscence is not expected; it usually occurs in obese patients. Wound infection is a complication that will take days to develop. Abscess formation is a complication that will take days to develop.
A lactating woman has developed thromboembolism. Which prescribed medication would the nurse anticipate providing teaching for if the client wishes to continue breast-feeding? 1. Aspirin 2. Heparin 3. Dicumarol 4. Phenindione
Answer: 2. Heparin Rationale: Heparin is the medication of choice to treat thromboembolism in a lactating woman because it is not absorbed in the breast milk. Aspirin may cause severe bleeding, so it is not preferred. Dicumarol may cause a hemorrhage and therefore is not preferred. Phenindione may cause a bruising effect and is not the medication of choice.
A client with a pulmonary embolus is intubated and placed on mechanical ventilation. Which nursing action is important when suctioning the endotracheal tube? 1. Applying negative pressure while inserting the suction catheter 2. Hyperoxygenating with 100% oxygen before and after suctioning 3. Suctioning two to three times in succession to effectively clear the airway 4. Using rapid movements of the suction catheter to loosen secretions
Answer: 2. Hyperoxygenating with 100% oxygen before and after suctioning Rationale: Suctioning also removes oxygen, which can cause cardiac dysrhythmias; the nurse should try to prevent this by hyperoxygenating the client before and after suctioning. Suction should be applied only while removing the catheter to prevent trauma to the trachea. Suction only as needed; excessive suctioning irritates the mucosa, which increases secretion production. Using rapid movements of the suction catheter to loosen secretions may cause tracheal damage.
When a client develops a venous thrombosis in the left calf, the nurse will monitor for which possible complication? 1. Embolic stroke 2. Pulmonary embolism 3. Myocardial infarction 4. Ischemia of the left foot
Answer: 2. Pulmonary embolism Rationale: Because the venous system returns blood to the right side of the heart and then blood flows to the pulmonary circulation, emboli from the venous thrombosis may cause pulmonary embolism. Embolic stroke occurs with thrombus formation in the left atrium or ventricle. Myocardial infarction occurs when thrombus forms over ruptured coronary artery plaque. Ischemia of the foot would occur with embolus in the distal arterial system.
Which education would the nurse provide to the family of a 10-year-old child diagnosed with hemophilia about the genetic inheritance of the condition? 1. It follows the Mendelian law of inherited disorders. 2. The mother is a carrier of the disorder but usually is not affected by it. 3. It is an autosomal dominant disorder in which the woman carries the trait. 4. A carrier may be male or female, but the disease occurs in the sex opposite that of the carrier.
Answer: 2. The mother is a carrier of the disorder but usually is not affected by it. Rationale: The hemophilia gene is carried on the X chromosome but is recessive. The female is the carrier (an unaffected XO and an affected XH). If the male receives the affected XH (XHYO), he will have the disorder. Hemophilia is carried by the female; the Mendelian laws of inheritance are not sex specific. Hemophilia is a sex-linked recessive disorder. Only females carry the trait; usually males are affected.
The parents of a child who has just been diagnosed with hemophilia type A ask the nurse about risk of hemophilia for future children after stating that the mother is a carrier of the hemophilia gene. Which response would the nurse make? 1. Probably not, because there is a 50% risk of a mother who is a carrier transmitting the disease, and 1 child already has the condition. 2. With each pregnancy, there is a 50% chance of a carrier transmitting the condition or being a carrier, depending on the gender of the child. 3. Definitely, because 1 child has hemophilia, all future pregnancies will result in children with the condition. 4. If the father has the condition and the mother is a carrier, all future children automatically will have hemophilia.
Answer: 2. With each pregnancy, there is a 50% chance of a carrier transmitting the condition or being a carrier, depending on the gender of the child. Rationale: With each pregnancy, there is a 50% chance of a carrier transmitting the condition or being a carrier, depending on the gender of the child. The odds are the same with each pregnancy and do not change based upon a previous pregnancy. One child currently having the condition does not affect this pregnancy. A recessive trait will not automatically mean all future pregnancies will result in children with hemophilia. If the father has the condition and the mother is a carrier, this does not guarantee that the child will inherit the condition.
The spouse of a client who had coronary artery bypass graft (CABG) surgery asks why there is a dressing on the client's left leg. Which explanation would the nurse give? 1. 'This is the access site for the heart-lung machine.' 2. 'A filter is inserted in the leg to prevent embolization.' 3. 'A vein in the leg was used to bypass the coronary artery.' 4. 'The arteries in the extremities are examined during surgery.'
Answer: 3. 'A vein in the leg was used to bypass the coronary artery.' Rationale: The response that a vein in the leg was used to bypass the coronary artery provides information and reduces anxiety. The nurse understands that the greater saphenous vein of the leg is used to bypass the diseased coronary artery. Cardiopulmonary bypass (extracorporeal circulation) is accomplished by placement of a cannula in the right atrium, vena cava, or femoral vein to withdraw blood from the body; blood is returned to the body via a cannula in the aorta or the femoral artery. A filter is not inserted in the leg to prevent embolization during a coronary artery bypass graft (CABG). The arteries in the extremities are not examined during a CABG.
A client with cirrhosis is scheduled for a liver biopsy. The client asks if there are any postprocedural risks. How would the nurse respond? 1. 'The major risk is pneumonia.' 2. 'The major risk is site infection.' 3. 'The major risk is bleeding.' 4. 'The major risk is liver failure.'
Answer: 3. 'The major risk is bleeding.' Rationale: The major postprocedural risk for this client is bleeding. In many clients with liver dysfunction, such as cirrhosis, the liver has lost its ability to synthesize proteins, such as clotting factors. The major postprocedural risks are not pneumonia, infection, or liver failure; bleeding is a higher risk.
The nurse instructs a client that, in addition to building bones and teeth, calcium is also important for what? 1. Bile production 2. Blood production 3. Blood clotting 4. Digestion of fats
Answer: 3. Blood clotting Rationale: Calcium is important for blood coagulation. When tissue damage occurs, serum calcium is necessary to promote coagulation by activating certain clotting factors. Calcium acts as a catalyst in the clotting process in both the extrinsic and intrinsic pathways. Calcium is responsible for a number of body functions, such as bone health, blood clotting, and muscle contraction and nerve impulses; however, it is not directly related to bile and blood production or digestion of fats.
When caring for a client with a possible pulmonary embolism, the nurse will anticipate preparing the client for which test? 1. Chest x-ray 2. Thoracic ultrasound 3. Helical computed tomography (CT) 4. Magnetic resonance imaging (MRI)
Answer: 3. Helical computed tomography (CT) Rationale: Helical CT is the most commonly used to detect pulmonary embolism. Chest x-ray may be normal with pulmonary embolism and is not useful as a diagnostic tool. Thoracic ultrasound might be used for pleural effusion, but not to diagnose pulmonary embolism. MRI testing is not used for diagnosis of pulmonary embolism.
A client experiences gastrointestinal (GI) bleeding, and the health care provider prescribes a blood transfusion. While receiving the blood, the client develops flank pain, chills, and fever. Which type of transfusion reaction would the nurse conclude that the client probably is experiencing? 1. Allergic 2. Pyrogenic 3. Hemolytic 4. Anaphylactic
Answer: 3. Hemolytic Rationale: A hemolytic transfusion reaction results from a recipient's antibodies that are incompatible with transfused red blood cells; it is called a type II hypersensitivity. The clinical findings are a result of red blood cells hemolysis, agglutination, and capillary plugging. An allergic transfusion reaction is the result of an immune sensitivity to foreign serum protein; it is called a type I hypersensitivity, and associated clinical findings include urticaria, wheezing, dyspnea, and shock. Bacterial pyrogens are present in contaminated blood and can cause a febrile transfusion reaction; associated clinical findings include fever and chills, but not flank pain. An anaphylactic reaction may occur with an allergic transfusion reaction.
The nurse is admitting a client to the unit after fetal death was confirmed by ultrasound. While initiating intravenous (IV) therapy, the nurse notes blood continually oozing from the puncture site. Which is the nurse's next action? 1. Restarting the line distal to the initial site 2. Starting the prescribed infusion of oxytocin 3. Informing the primary health care provider of this finding 4. Placing an oxygen mask on the client and setting the flow rate at 8 L/min
Answer: 3. Informing the primary health care provider of this finding Rationale: Oozing from a venipuncture site is a sign that disseminated intravascular coagulopathy (DIC) is developing. This pathological form of clotting causes widespread bleeding and clotting. It is never a primary diagnosis; it always results from some problem that has triggered the clotting cascade. The primary health care provider must be informed immediately, because this diagnosis will change the client's plan of care. There is no information indicating the need for a different IV site. Also, subsequent venipunctures must be proximal and not distal to previous sites. Delivery will likely be managed initially with oxytocin; however, this is not the first action to be taken in regard to an oozing IV site. Generally oxygen is started for signs of hypoxia, fetal or maternal; because there is not fetal indication for oxygen and no information indicating maternal hypoxia, application of oxygen is not the next intervention.
Which procedural contraindication would the nurse evaluate in a client suspected of carcinoma of the liver and scheduled for a liver biopsy? 1. Confusion, disorientation, and jaundice 2. Presence of any infectious disease process 3. International normalized ratio (INR) greater than 4.5 4. Client's food intake is high in vitamins E and phytonadione
Answer: 3. International normalized ratio (INR) greater than 4.5 Rationale: A normal INR range is 0.7 to 1.8. INR values over 4.5 increase the risk of major hemorrhage. Correction of the INR must occur before the biopsy to prevent hemorrhage. Confusion, disorientation, and jaundice are not a contraindication for a liver biopsy; however, if present, the client may need support, and the heath care provider may need assistance but may still perform the biopsy. An infectious disease does not prevent the health care provider from performing a liver biopsy. The client needs phytonadione (vitamin K) to produce prothrombin; however, this does not guarantee clotting activity because the liver also has to make an adequate supply of clotting factors and proteins for blood clotting to occur. Vitamin E is not involved in blood clotting.
A client is admitted to the hospital with suspected liver disease, and a needle biopsy of the liver is performed. After the procedure, the nurse would maintain the client in which position? 1. Supine 2. Semi-Fowler's 3. Right side-lying 4. Dorsal recumbent
Answer: 3. Right side-lying Rationale: The liver is on the right side of the body; the right side-lying position provides pressure at the needle insertion site and promotes hemostasis. The supine position does not provide pressure over the liver or promote hemostasis. The semi-Fowler's position does not provide pressure over the liver or promote hemostasis. The dorsal recumbent position keeps the liver uppermost, thus no pressure is exerted to promote hemostasis.
When the thigh-high antiembolism stockings that have been prescribed for a client with varicose veins fit on the lower legs but are too small over the thighs, which action would the nurse take? 1. Slightly slit the top of the stockings to relieve pressure. 2. Leave the antiembolism stockings off to prevent tissue damage. 3. Roll the top of the stockings to below the knees to limit popliteal pressure. 4. Ask the health care provider if an elastic bandage can be used in place of the stockings.
Answer: 4. Ask the health care provider if an elastic bandage can be used in place of the stockings. Rationale: An elastic bandage can be adjusted to the varying proportions of the client's leg. Cutting the stockings to relieve pressure is inappropriate and will decrease the effectiveness of the stockings. Leaving the antiembolism stockings off to prevent tissue damage is unsafe; this permits venous stasis. Rolling the top of the stockings to below the knees to limit popliteal pressure will increase the pressure on the popliteal space, which increases venous stasis and the risk of thrombophlebitis.
When caring for an older adult with coronary artery disease, which modification in the plan of care would the nurse make because of the client's age? 1. Decrease warm-up and cool-down times around exercise. 2. Disregard arrhythmias, because they are common in the aging adult. 3. Hold all anticoagulants, because the older adult has increased risk of side effects. 4. Assess for less common anginal symptoms like shortness of breath and gastric discomfort.
Answer: 4. Assess for less common anginal symptoms like shortness of breath and gastric discomfort. Rationale: The older adult may not present typical chest pain symptoms for coronary disease but instead may have complaints like shortness of breath and gastric discomfort. Warm-up and cool-down times should be increased around exercise. Arrhythmias are more common but still need attention. Anticoagulation side effects are increased in the older adult, but anticoagulants still are administered for their therapeutic effect.
After donning gloves, which action would the nurse take first after discovering a large amount of blood under the buttocks of a client who had a cardiac catheterization through the femoral artery? 1. Apply pressure to the site. 2. Obtain vital signs. 3. Change the client's gown and bed linens. 4. Assess the catheterization site.
Answer: 4. Assess the catheterization site. Rationale: Observing standard precautions is the first priority when dealing with any body fluid, followed by assessment of the catheterization site as the second priority. This action establishes the source of the blood and determines how much blood has been lost. Once the source of the bleeding is determined, the priority goal for this client is to stop the bleeding and ensure stability of the client by monitoring the vital signs. Changing the client's gown and bed linens is not necessary until the bleeding is controlled and the client is stabilized.
A health care provider prescribes tissue plasminogen activator (t-PA) to be administered intravenously over 1 hour for a client experiencing a myocardial infarction. Which assessment component can identify problems caused by this medication's effect? 1. Respiratory rate 2. Peripheral pulses 3. Level of consciousness 4. Intravenous insertion site
Answer: 4. Intravenous insertion site Rationale: The most common adverse effect of a t-PA is bleeding because of the thrombolytic action of the medication. Sites of invasive procedures, such as intravenous (IV) sites, have an increased tendency to bleed. Although respiratory rate, peripheral pulses, and level of consciousness are important for any client with a decreased cardiac output, they are not specific to the administration of a tissue plasminogen activator.
Which information will the nurse include when teaching a client with venous insufficiency about prevention of venous thrombosis? 1. Wear snug-fitting pants. 2. Sit with the knees flexed. 3. Apply warm soaks to the legs daily. 4. Put on compression stockings before arising.
Answer: 4. Put on compression stockings before arising. Rationale: Donning compression stockings before getting out of bed provides support and promotes venous return; applying stockings while the legs are horizontal ensure that the stockings are in place before dependent edema occurs. Wearing snug-fitting pants will cause constriction that will may decrease venous return and increase venous thrombus risk. Sitting with the knees flexed promotes venous stasis and the formation of venous thrombus. Warm soaks resolve inflammation; they do not prevent the development of thrombophlebitis.
