A client in a health care facility is receiving the thrombolytic drug reteplase. Which nursing diagnosis would be most likely?
A) Anxiety
B) Constipation
C) Disturbed Sensory Perception
D) Ineffective Tissue Perfusion
Ans: A
Feedback:
The nursing diagnoses for a client receiving the thrombolytic drug reteplase should include Anxiety. Constipation, disturbed sensory perception, and ineffective tissue perfusion would be unlikely for the client receiving reteplase.
You might also like to view...
A nurse has an interview with the human resources (HR) director for a night shift position on a medical surgical unit. The nurse enters the HR director?s office, doesn?t make eye contact when meeting the director, and is very timid
Toward the end of the interview the HR director asks the nurse if she has and questions. The nurse states, ?No, I think I?ve learned all I need to know.? What impression has this nurse given the HR director? 1. Lack of interest in the position 2. Shyness and the inability to manage people 3. Rudeness 4. Laziness
Which attribute is necessary for the nurse who wishes to be a client advocate?
1. Restricting work to those areas in which the nurse has expertise and experience. 2. Referring any political action needs to a political action committee. 3. Avoiding conflicts with physicians and healthcare agency administrators. 4. Being assertive in representing the needs of the client and family.
The nurse is reviewing fluid intake and output with a student nurse. What would be the best response by the student nurse of fluids that would be recorded as output?
1 . Tube feeding 2 . Vomitus 3 . Bleeding 4 . Thoracentesis A) 1, 2, 3 B) 1, 2, 4 C) 1, 3, 4 D) 2, 3, 4
The nurse is providing discharge teaching for a patient with diarrhea. Which of the following statements, if made by the patient, indicates that teaching has been effective?
a. "It is important that I increase fluid intake to prevent dehydration." b. "I am at increased risk for a ruptured bowel, so I must remain on bedrest." c. "I should tell future health-care workers that I've been diagnosed with obstipation." d. "My risk for a urinary tract infection is very high, so I should call the doctor if I have a pain."