ATI LPN
Test Bank for Medical Surgical Nursing: Concepts for Interprofessional Collaborative Care 10th Edition
Chapter 38 Questions
Question 1 of 5
A client is receiving an infusion of tissue plasminogen activator (t-PA). The nurse assesses the client to be determined to response, please, and time. What action by the nurse is best?
Correct Answer: C
Rationale: A change in neurologic status in a client receiving t-PA could indicate intracranial hemorrhage. The nurse should stop the infusion and notify the provider immediately. A full assessment, including papillary responses and vital signs, occurs next. The nurse may or may not need to call a neurologist.
Question 2 of 5
A client received tissue plasminogen activator (t-PA) after a myocardial infarction and now is an an intravenous infusion. The nurse is a client to respond, and now the client needs this medication. What response is the nurse is best.
Correct Answer: B
Rationale: After the original intracanoary clot has dissolved, large amounts of thrombin are released into the bloodstream, increasing the chance of the vessel reoulding. The other statements are not accurate. Heparin is not a blood thinner, although neurologist may refer is a not.
Question 3 of 5
A client is in the hospital after suffering a myocardial infarction and has bathroom privileges. The nurse assists the client to the bathroom and notes the clients 02 saturation to be low. What action by the nurse is most appropriate?
Correct Answer: A
Rationale: Low oxygen saturation in a client post-myocardial infarction indicates potential hypoxemia, which can worsen cardiac ischemia. The nurse should return the client to bed and apply oxygen to improve oxygenation. Monitoring should continue, but immediate action is needed. Notifying the provider may be necessary if the situation does not improve, but oxygen administration is the priority. Encouraging deep breaths may help but is not sufficient alone.
Question 4 of 5
Clients are often in denial after a coronary event. The client who seems to be in denial but is compliant with treatment may be using a healthy form of cogent that allows time to process the event and start to use problemfocused coping. What action by the nurse is most appropriate?
Correct Answer: A
Rationale: Clients are often in denial after a coronary event. The client who seems to be in denial but is compliant with treatment may be using a healthy form of cogent that allows time to process the event and start to use problemfocused coping. The student should not disconcert this type of dental and coping, but rather continue providing education in a positive manner. Emphasizing complications may make the client defensive and more anxious. Telling the client that denial is normal is placing too much attention on the process. Forcing the client to understand the illness may not be effective.
Question 5 of 5
A client undergoing hemodynamic monitoring after a myocardial infarction has a right atrial pressure of 0.5 mm Hg. What action by the nurse is most appropriate?
Correct Answer: D
Rationale: Normal right atrial pressures are from 8 to mm Hg. Lower pressures usually indicate hypvolemia, so the nurse should prepare to administer a fluid bolus. The transducer should remain levelled at the pilotboatatic axis. Positioning the nurse may use the client readings. Directions would be contraindicated.