A client who is admitted with an acute coronary syndrome (ACS) receives eptifibatide, a glycoprotein (GP) (IB IIIA. inhibitor. Which assessment finding places the client at greatest risk?
Unresponsive to painful stimuli.
Presence of hematemesis.
Incontinent with blood in urine.
Blood pressure of 100/60 mm Hg.
The Correct Answer is B
A. Unresponsiveness to painful stimuli indicates a potential neurological issue but does not directly correlate with the risk of bleeding associated with eptifibatide use.
B. Hematemesis indicates gastrointestinal bleeding, which is a significant concern in patients on eptifibatide, as it increases the risk of serious bleeding complications.
C. Blood in urine (hematuria) can indicate a urinary tract issue or bleeding but is less critical than gastrointestinal bleeding in this context.
D. A blood pressure of 100/60 mm Hg may indicate some degree of hypotension but is not as urgent as identifying active bleeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. While measuring vital signs is important, it does not directly address the client's immediate difficulty in breathing. Prioritizing the client's comfort and respiratory function is more critical in this situation.
B. Assisting the client to a high Fowler's position helps facilitate lung expansion and may alleviate dyspnea. This position can improve respiratory function by reducing abdominal pressure on the diaphragm.
C. Deep breathing exercises are beneficial but are not the immediate priority; positioning the client for better airflow should come first.
D. Auscultating breath sounds is necessary for assessing the underlying cause of dyspnea, but this should be done after ensuring the client is in a position that maximizes their breathing capacity.
Correct Answer is B
Explanation
A. Continue to provide life support until a thorough search for a guardian is completed: While continuing life support is essential, the delay involved in waiting for a guardian to be located could jeopardize the patient's life. Immediate surgery is necessary to save the client, and life support is unlikely to be sufficient on its own.
B. Carry on with surgical preparation of the client without a signed informed consent: In cases of medical emergencies where the patient is unable to provide consent (such as being unresponsive), the healthcare team can proceed with necessary life-saving procedures without waiting for formal written consent. The principle of implied consent applies in this scenario, where it is assumed the patient would consent to life-saving treatment if they were able to do so.
C. Ask the client's friend to sign the informed consent since the client is unresponsive: The friend does not have the legal authority to provide informed consent unless they are a legal guardian or have been granted specific decision-making powers. Consent should not be obtained from a non-guardian in this situation.
D. Notify the unit manager that an emergency court order is needed to allow surgery: While emergency court orders can sometimes be used in certain legal situations, they are unnecessary when the immediate need for life-saving surgery overrides the formalities of obtaining a signed consent. The focus should be on proceeding with treatment to preserve life.
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