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 the body may recognize as an antigen, leading to the production of antibodies. This can result in an allergic reaction or anaphylaxis. Pulmonary embolism (A) and acute myocardial infarction (B) are potential complications of a blood clot but not directly related to streptokinase use. Acute gastric irritation (D) is not a common adverse reaction to streptokinase.

Correct Answer: C

Rationale: The correct answer is C: Atrial depolarization. The P wave on an ECG represents the depolarization of the atria, indicating the contraction of the atria. This is the first electrical activity that occurs in the heart's conduction system. Ventricular depolarization (choice A) is represented by the QRS complex, while ventricular repolarization (choice B) is represented by the T wave. Atrial repolarization (choice D) is typically hidden within the QRS complex, making it difficult to identify on a standard ECG. Therefore, the P wave best represents atrial depolarization due to its timing and shape on the ECG waveform.

Correct Answer: C

Rationale: The correct answer is C: Type 2 second degree AV block. This is because in this type of AV block, there is a consistent pattern of dropped QRS complexes due to intermittent failure of AV conduction. The P waves are normal but are not followed by QRS complexes, leading to a slow ventricular rate. In contrast, in normal sinus rhythm (choice A), there is a 1:1 relationship between P waves and QRS complexes. Type 1 second degree AV block (choice B) presents with progressively lengthening PR intervals until a QRS complex is dropped, not a consistent pattern like in Type 2. Third-degree AV block (choice D) is characterized by complete dissociation between atrial and ventricular activity, resulting in an independent ventricular rate typically faster than 40.

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 that the patient comprehends the importance of seeking immediate medical attention if the chest pain is not relieved by the medication. Explanation for why other choices are incorrect: A: Choice A is incorrect because nausea is not a common side effect of nitroglycerin. B: Choice B is incorrect as nitroglycerin is used to relieve chest pain during an angina attack, not just when chest pain is present. C: Choice C is incorrect as nitroglycerin works by dilating blood vessels to improve blood flow, not by preventing clot formation. In summary, choice D is correct as it reflects the patient's understanding of the appropriate action to take in case of persistent chest pain after taking nitroglycerin, while the other choices demonstrate misunderstandings about nitroglycerin use.

Correct Answer: C

Rationale: The correct answer is C because a decrease in the level of consciousness during thrombolytic therapy for acute myocardial infarction can indicate a potential intracranial hemorrhage, a serious complication. Stopping the drug infusion is crucial to prevent further bleeding and worsening the patient's condition. Choices A, B, and D are incorrect because bleeding from the gums, an increase in blood pressure, or a nonsustained episode of ventricular tachycardia are not immediate indicators of a life-threatening complication requiring immediate cessation of the drug infusion.