The client is on streptokinase for a blood clot. What adverse reaction should the nurse be looking out for?

Correct Answer: C

Rationale: The correct answer is C: Antibody production against the streptokinase. Streptokinase is a foreign protein that can trigger an immune response leading to the production of antibodies. This can result in an allergic reaction or anaphylaxis. Pulmonary embolism (choice A) and acute myocardial infarction (choice B) are not adverse reactions specific to streptokinase. Acute gastric irritation (choice D) is also not a common adverse reaction of streptokinase therapy.

Correct Answer: C

Rationale: The correct answer is C: Atrial depolarization. The P wave on an ECG represents the electrical activity associated with atrial depolarization, specifically the contraction of the atria. This is the first wave seen on an ECG and indicates the initiation of the cardiac cycle. Ventricular depolarization, represented by the QRS complex, occurs after the P wave. Ventricular repolarization, represented by the T wave, occurs after ventricular depolarization. Atrial repolarization is not typically seen on a standard ECG as it is masked by the QRS complex.

Correct Answer: C

Rationale: The correct answer is C: Type 2 second degree AV block. In this type of AV block, there is a consistent pattern of dropped QRS complexes due to intermittent failure of AV conduction. The ventricular rate of 40 indicates a slow conduction of impulses from the atria to the ventricles. The presence of normal and unconnected P waves suggests that some P waves are conducted to the ventricles (resulting in QRS complexes) while others are blocked. This pattern is characteristic of Type 2 second degree AV block. Summary: A: Normal sinus rhythm - Incorrect, as the EKG findings do not show a normal sinus rhythm. B: Type 1 second degree AV block - Incorrect, as this type is characterized by a progressively prolonged PR interval leading to a dropped QRS complex, which is not seen in this case. D: Third degree AV block - Incorrect, as in third degree AV block, there is complete dissociation between the atria and

Correct Answer: D

Rationale: The correct answer is D because it demonstrates the patient's understanding of the appropriate action to take if chest pain persists after taking nitroglycerin. This response shows recognition of the need for timely medical intervention if the medication is not effective, aligning with the goal of nitroglycerin use in managing angina. A is incorrect because nausea is a common side effect, but not the key indicator of effective teaching. B is incorrect as it suggests using nitroglycerin only during chest pain, missing the preventive aspect. C is incorrect as it misinterprets the mechanism of action of nitroglycerin, which primarily dilates blood vessels to improve blood flow, not prevent clot formation.

Correct Answer: C

Rationale: The correct answer is C: a decrease in level of consciousness. This indicates a potential complication such as intracranial hemorrhage, which is a serious side effect of thrombolytic therapy. Stopping the drug infusion is crucial to prevent further harm. Explanation of why the other choices are incorrect: A: Bleeding from the gums is a common side effect of thrombolytic therapy and does not necessarily warrant stopping the drug infusion unless it is severe or uncontrollable. B: An increase in blood pressure may be a normal response to the medication and does not necessarily require stopping the infusion. D: A nonsustained episode of ventricular tachycardia is a common arrhythmia in acute myocardial infarction and may not require stopping the drug infusion unless it progresses to a sustained or unstable rhythm.