A client is admitted to the emergency department (ED) and diagnosed as having an ST-segment-elevation myocardial infarction (STEMI). Which question should the nurse ask to determine whether the client is a candidate for fibrinolytic therapy?
Can you describe the quality of your chest pain?
Do you take aspirin on a daily basis?
Is there any family history of heart disease?
What time did your chest pain begin?
The Correct Answer is D
A. Can you describe the quality of your chest pain?: While important for initial assessment and differentiating types of chest pain, the quality of pain does not determine eligibility for fibrinolytic therapy.
B. Do you take aspirin on a daily basis?: Daily aspirin use is relevant for antiplatelet therapy but does not determine candidacy for fibrinolytic treatment. It may influence bleeding risk, but timing of symptom onset is more critical.
C. Is there any family history of heart disease?: Family history provides information on risk factors but does not impact the immediate decision regarding fibrinolytic therapy.
D. What time did your chest pain begin?: Fibrinolytic therapy is most effective when administered within a specific time window, typically within 12 hours of symptom onset. Determining the onset of chest pain is essential to establish whether the client is a candidate for thrombolytic treatment and to maximize benefit while minimizing risk.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. 1170 mL: Using the Parkland formula (4 mL × body weight in kg × % TBSA burned), the total fluid for the first 24 hours is calculated: 4 × 78 × 60 = 18,720 mL. Half of this (9,360 mL) is administered in the first 8 hours. To determine the hourly rate: 9,360 ÷ 8 = 1,170 mL/hour. This is the correct rate for the initial 8-hour resuscitation period.
B. 585 mL: This is half of the correct hourly rate. Administering only 585 mL/hour would under-resuscitate the client, risking hypoperfusion and shock.
C. 4680 mL: This number may represent half of the total 24-hour fluid requirement, but it is not the per-hour rate. Administering all 4,680 mL at once would be unsafe and could cause fluid overload.
D. 9360 mL: This is the total volume for the first 8 hours, not the hourly rate. Delivering the entire 9,360 mL at once would be extremely dangerous and could result in cardiovascular compromise and pulmonary edema.
Correct Answer is B
Explanation
A. The client's pulse is slightly tachycardic: Mild tachycardia may occur due to pain, anxiety, or mild physiological stress, but it is not immediately life-threatening in the context of a head injury.
B. The client is more difficult to arouse: A decreased level of consciousness is a critical sign of increased intracranial pressure or worsening brain injury. Rapid assessment and intervention are essential to prevent further neurological deterioration or herniation.
C. The client complains of a headache at pain level 5 of a 10-point scale: Moderate headache is concerning and requires monitoring and management, but it does not indicate imminent neurological compromise.
D. The client's blood pressure increases from 120/54 to 136/62 mmHg: A mild rise in blood pressure may be compensatory or stress-related and does not by itself signal acute deterioration. It is less urgent compared to changes in mental status.
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