A client with an acute myocardial infarction (MI) is given a thrombolytic medication, aspirin, and IV heparin in the emergency department. Which finding indicates the client is having a satisfactory response?

Activated partial thromboplastin time (aPTT) is 2 times the control value.

S3 heart sounds are present with auscultation.

Cardiac tracing shows 1.2 mm wide Q waves half the height of the complex.

Guaiac test of the stools is positive.

Answer and Explanation

The Correct Answer is A

A.   An aPTT that is 2 times the control value indicates that the heparin is effectively anticoagulating the blood, which is a desired outcome in managing MI to prevent clot formation.
B.   S3 heart sounds can indicate heart failure and are not a sign of a satisfactory response to MI treatment.
C.   Wide Q waves indicate a previous infarction but do not reflect the immediate effectiveness of the treatment.
D.   A positive guaiac test indicates gastrointestinal bleeding, which is a potential complication rather than a satisfactory response.

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Correct Answer is ["B","E"]

Explanation

A. Serum potassium within the reference range is not typically a cause for concern in this scenario.
B. A hemoglobin A1C level of 7% indicates poor glycemic control and may suggest the need for adjustment in diabetes management, as it exceeds the recommended target range.
C. Total cholesterol within the reference range is not the most significant finding to report in this scenario.
D. Hematocrit within the reference range is not the most significant finding to report in this scenario.
E. A random plasma glucose level of 200 mg/dl (11.1 mmol/L) is indicative of hyperglycemia and requires attention as it suggests poor glycemic control, potentially related to diabetes.

A. Heart rate 121 beats/minute B. Capillary refill 2 seconds C. Respirations 28 breaths/minute with shallow breathing D. Radial and pedal pulses 2+ E. Severe abdominal pain in right lower quadrant F. Feels anxious G. Temperature 100.8° F (38.2° C) H. Vomiting small amounts of green bile I. Blood pressure 115/76 mm Hg

Correct Answer is ["A","C","E","G","H"]

Explanation

A. Tachycardia indicates the body is responding to pain, infection, or potential sepsis. It's a critical vital sign indicating the body's stress response.
B. Tachypnea can be a response to pain or anxiety but also indicates the need for careful monitoring of respiratory status, especially postoperatively.

C. A capillary refill of 2 seconds is within the normal range and indicates adequate peripheral perfusion.
D. Radial and pedal pulses 2+ are within the normal range and indicates adequate peripheral perfusion.
E. Severe abdominal pain in the right lower quadrant is a primary symptom of appendicitis, which is confirmed by the CT scan showing a dilated appendix and fat stranding. Immediate attention is needed to address potential complications such as rupture.
F. Feeling anxious needs to be managed to promote patient comfort. However, it doesn’t need to be managed immediately since it is not life-threatening.
G. Fever is a sign of infection or inflammation, common in appendicitis. Monitoring and managing fever is crucial in preventing further complications.
H. Bilious vomitus is a common finding in appendicitis and may indicate that the inflammation has progressed to a point where it is causing a blockage in the intestines. This obstruction can lead to increased pressure within the abdominal cavity and compromise blood flow, potentially resulting in a life-threatening situation.
I. A blood pressure of 115/76 mm Hg is within normal limits and indicates stable hemodynamics at this point.

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A client with an acute myocardial infarction (MI) is given a thrombolytic medication, aspirin, and IV heparin in the emergency department. Which finding indicates the client is having a satisfactory response?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["B","E"]

Explanation

Exhibits The nurse is caring for the client. Which of the following assessment findings should the nurse prioritize?

Correct Answer is ["A","C","E","G","H"]

Explanation

The healthcare provider prescribes 1 unit (350 mL) of packed red blood cells (PRBC) to infuse over 4 hours. The IV administration set delivers 15 gtt/mL. How many gtt/min should the nurse regulate the infusion? (Enter the numeric value only. Round to the nearest whole number.)

Which instruction should the nurse delegate to an unlicensed assistive personnel (UAP)?

A 2-year-old is brought to the emergency department (ED) with a history of several days of rhinitis and now exhibits a productive barking cough and difficulty breathing. Which additional finding should alert the nurse that the child is experiencing respiratory distress?

Four hours after surgery, a client reports nausea and begins to vomit. The nurse notes that the client has a scopolamine transdermal patch applied behind the ear. Which action should the nurse take?

A client exposed to tuberculosis is scheduled to begin prophylactic treatment with isoniazid. Which information is most important for the nurse to note before administering the initial dose?

In evaluating the effectiveness of a postoperative client's intermittent pneumatic compression devices, which assessment is most important for the nurse to complete?

A client's telemetry monitor indicates ventricular fibrillation (VF). Which action should the nurse implement immediately?

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