A patient admitted with an acute coronary syndrome (ACS) is receiving eptifibatide, a glycoprotein (GP) IIb IIIa inhibitor.
Which assessment finding poses the greatest risk to the patient?

Choice A rationale

While securing the room with padded walls and minimal furnishings is an important aspect of seclusion, it is not the most important intervention immediately after seclusion. The safety of the client is paramount, and observing for extrapyramidal symptoms, such as dystonia, is crucial as haloperidol, an antipsychotic medication known to have the potential for causing extrapyramidal side effects, was administered.

Choice B rationale

Releasing the client as soon as composure is regained is not the most important intervention. The client’s mental and physical health needs to be continuously monitored, especially for side effects of the medication administered.

Choice C rationale

Providing one-on-one observation at all times is important, but it is not the most important intervention immediately after seclusion. The priority is to monitor for any adverse effects of the medication administered.

Choice D rationale

Observing for extrapyramidal symptoms, such as dystonia, is the most important intervention immediately after seclusion because haloperidol is an antipsychotic medication known to have the potential for causing extrapyramidal side effects.

Choice A rationale

Assigning the newly hired UAP to clients who require the least complex level of care might not be the best approach. While it might seem logical to assign less complex cases to a new hire, this could limit the UAP’s opportunities for learning and growth.

Choice B rationale

Reviewing the UAP’s skills checklist and experience with the person who hired the UAP is an important step, but it might not be enough to ensure adequate care for all clients. The skills and experiences listed on a checklist might not fully reflect the UAP’s actual abilities in a real-world setting.

Choice C rationale

Asking the most experienced UAP on the team to partner with the newly hired UAP could be beneficial for mentorship and guidance. However, this might not be the most efficient use of resources, especially if the experienced UAP has to spend a significant amount of time supervising the new hire.

Choice D rationale

Assessing the newly hired UAP’s competency level by observing the UAP deliver care is the most effective way to ensure adequate care for all clients. This allows the nurse to directly evaluate the UAP’s skills and abilities in a real-world setting, and to provide immediate feedback and guidance as needed.