Which nursing actions would be of greatest importance in the management of a client preparing for angioplasty?
A) Inform client of diagnostic tests.
B) Remove hair from skin insertion sites.
C) Assess distal pulses.
D) Withhold anticoagulant therapy.
D
Feedback:
The nurse knows to withhold the anticoagulant therapy to decrease chance of hemorrhage during the procedure. The nurse does inform the client of diagnostic test, will assess pulses, and prep the skin prior to the angioplasty, but this is not the most important action to be taken.
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A client diagnosed with chronic disseminated intravascular coagulation is prescribed heparin. The nurse realizes that this medication is used to:
1. increase blood flow to the circulation. 2. increase blood clot formation. 3. decrease blood flow in the circulation. 4. decrease blood clot formation.
A male patient who has been prescribed isoniazid (INH, Nydrazid) reports that his breasts have enlarged since starting therapy. What is the nurse's best response?
a. "This is common with isoniazid and will disappear after you stop drug therapy." b. "Is the enlargement the same on both sides or is one breast larger than the other?" c. "If you are not having difficulty getting an erection, do not worry about this change." d. "I will report this problem to your prescriber and see if it is possible for you to stop taking this drug."
Which patients would be at risk for nutritional imbalances? The patient: Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply
1. Who is a stable, post-myocardial infarction 2. With renal failure 3. With slightly elevated liver enzymes 4. Who is intubated and sedated 5. With burns or excessive trauma
A nurse is working with a client who is delusional. The client says to the nurse, "The leaders of a religious cult are being sent to assassinate me." Which of the following is the best response by the nurse?
1. "I don't believe that what you are telling me is true." 2. "There are no religious cults in this area that are going to kill you." 3. "What makes you think that cult members are being sent to hurt you?" 4. "I don't know about a religious cult. Are you afraid that people are trying to hurt you?"