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 ["22"]

Explanation

To calculate the drip rate for an IV, you can use the formula: (Volume to be infused (mL) x Drop factor (gtt/mL)) / Time (min). For the prescribed 1 unit of PRBC at 350 mL to be infused over 4 hours with a drop factor of 15 gtt/mL, the calculation would be: (350 mL x 15 gtt/mL) / (4 hours x 60 minutes/hour). This simplifies to (5250 gtt) / (240 min), which equals 21.875 gtt/min. When rounded to the nearest whole number, the nurse should regulate the infusion to 22 gtt/min.

A. The client's need for pain medication should be determined. B. The nurse manager should be updated on the client's status. C. The client's status should be conveyed to the chaplain. D. The impending signs of death should be documented.

Correct Answer is A

Explanation

A. Ensuring comfort during the dying process is paramount in end-of-life care. Assessing and managing pain promptly supports quality of life and dignity in the client's final moments.
B. The nurse manager should be updated on the client's status. While communication with the nurse manager is important, it is not the immediate priority when a client is experiencing discomfort or pain.
C. The client's status should be conveyed to the chaplain. Involving spiritual care is important but secondary to addressing any immediate physical comfort needs of the client.
D. The impending signs of death should be documented. Documentation is important, but it is a secondary priority to the direct care and comfort needs of the client.

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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

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.)

Correct Answer is ["22"]

Explanation

A client with a prescription for "do not resuscitate" (DNR) begins to manifest signs of impending death. After notifying the family of the client's status, which priority action should the nurse implement?

Correct Answer is A

Explanation

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