a nurse is caring for a client who is to receive thrombolytic therapy which of the following factors should the nurse recognize as a contraindication

ATI RN

ATI Fundamentals Proctored Exam Quizlet

1. A client is to receive thrombolytic therapy. Which of the following factors should be recognized as a contraindication to the therapy?

A. Hip arthroplasty 2 weeks ago
B. Elevated sedimentation rate
C. Incident of exercise-induced asthma 1 week ago
D. Elevated platelet count

Correct answer: A

Rationale: Thrombolytic therapy involves the use of medications to dissolve blood clots. Hip arthroplasty (joint replacement surgery) performed recently is a contraindication to thrombolytic therapy due to the risk of bleeding. Elevated sedimentation rate, exercise-induced asthma, and elevated platelet count are not contraindications to thrombolytic therapy.

2. When is additional Vitamin C not required?

A. Infancy
B. Young adulthood
C. Childhood
D. Pregnancy

Correct answer: B

Rationale: Vitamin C requirements are increased during infancy, childhood, and pregnancy due to growth and development. However, during young adulthood, the body generally requires a consistent amount of Vitamin C as it is not undergoing rapid growth or physiological changes that necessitate an increase in Vitamin C intake.

3. To assess the kidney function of a patient with an indwelling urinary (Foley) catheter, the nurse measures the hourly urine output. When should she notify the physician?

A. Less than 30 ml/hour
B. 64 ml in 2 hours
C. 90 ml in 3 hours
D. 125 ml in 4 hours

Correct answer: A

Rationale: Notifying the physician is necessary when the urine output is less than 30 ml/hour as it indicates impaired kidney function. Adequate urine output is essential for monitoring kidney function, and a urine output less than 30 ml/hour could suggest potential renal issues that require medical attention.

4. When a client is comatose and has advance directives stating a desire to avoid life-sustaining measures, but the family wants these measures, what action should the nurse take?

A. Arrange for an ethics committee meeting to address the family's concerns.
B. Support the family's decision and initiate life-sustaining measures.
C. Complete an incident report.
D. Encourage the family to contact an attorney.

Correct answer: A

Rationale: In this scenario, the nurse should prioritize the client's wishes as outlined in the advance directives. By arranging for an ethics committee meeting, the nurse can facilitate discussions between the family and healthcare team to ensure that the client's wishes are respected while addressing the concerns of the family. This approach promotes ethical decision-making and collaborative communication among all involved parties, ultimately aiming to provide the best possible care for the client while considering their autonomy and preferences.

5. What is a nurse's role in health promotion?

A. Conducting health risk appraisals
B. Educating clients to be effective health consumers
C. Implementing worksite wellness programs
D. None of the above

Correct answer: B

Rationale: A nurse plays a crucial role in health promotion by educating clients to be effective health consumers. This involves empowering individuals to make informed decisions about their health, access appropriate healthcare services, and engage in healthy behaviors to prevent illness and promote well-being. The other choices are not entirely accurate in describing the primary role of a nurse in health promotion. While nurses may conduct health risk appraisals and implement worksite wellness programs as part of their responsibilities, their central focus is on educating and empowering individuals to take control of their health.