A patient has intra-arterial (art-line) blood pressure monitoring after a myocardial infarction (MI). Following the angioplasty procedure, the nurse notes that the patient's heart rate has increased from 88 to 110 beats/min, and the blood pressure dropped from 120/82 to 100/60 mm Hg. What action by the nurse is most appropriate?

Medicate the patient for pain.

Allow the patient to rest quietly.

Assess the patient for bleeding.

Document the findings in the chart.

Answer and Explanation

The Correct Answer is C

Choice A reason: Medicating the patient for pain is not the most appropriate immediate action in this situation. While pain management is important, the primary concern should be addressing the significant changes in heart rate and blood pressure, which may indicate a more serious underlying issue.

Choice B reason: Allowing the patient to rest quietly is not the appropriate response to the noted changes in vital signs. The increase in heart rate and drop in blood pressure are signs that require immediate investigation and intervention, rather than passive observation.

Choice C reason: Assessing the patient for bleeding is the most appropriate action. The increase in heart rate and decrease in blood pressure following an angioplasty procedure are concerning for potential bleeding or hemorrhage, especially if the patient has an intra-arterial line. Quick assessment and intervention are crucial to address any bleeding and stabilize the patient's condition.

Choice D reason: Documenting the findings in the chart is necessary, but it should not be the immediate priority. The nurse must first assess and address the potential cause of the changes in vital signs, such as bleeding, before documenting the events.

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Correct Answer is A

Explanation

Choice A reason: Arterial Blood Gas (ABG) analysis is the best method to determine the effectiveness of treatments for a client in acute respiratory failure who is receiving mechanical ventilation. ABG provides essential information about the patient's oxygenation status, carbon dioxide levels, and acid-base balance. It allows healthcare providers to assess how well the lungs are oxygenating the blood and removing carbon dioxide. By analyzing the ABG results, the effectiveness of the mechanical ventilation and any necessary adjustments can be made to improve the client's respiratory status.

Choice B reason: Blood pressure monitoring is important for evaluating the overall cardiovascular status of a patient but is not the most specific assessment for determining the effectiveness of treatments in acute respiratory failure. While blood pressure can provide indirect information about cardiac output and perfusion, it does not directly reflect the patient's oxygenation and ventilation status, which are critical in the context of respiratory failure.

Choice C reason: Heart rate monitoring is useful for assessing the patient's hemodynamic status and detecting potential arrhythmias or other cardiac issues. However, it does not provide specific information about the effectiveness of treatments for acute respiratory failure. Heart rate alone cannot indicate how well the lungs are functioning or how effectively mechanical ventilation is supporting the patient's respiratory needs.

Choice D reason: Capillary refill is a simple and quick assessment of peripheral perfusion, indicating how well the blood is flowing to the extremities. While it can provide some information about the patient's circulatory status, it is not a reliable method for determining the effectiveness of treatments in acute respiratory failure. Capillary refill does not provide direct information about oxygenation, ventilation, or the overall respiratory status of the patient.

A. Increased serum calcium. B. Decreased serum ammonia. C. Increased ALT and AST. D. Decreased albumin. E. Elevated bilirubin. F. Elevated prothrombin time (PT).

Correct Answer is ["C","D","E","F"]

Explanation

Choice A reason: Increased serum calcium is not typically associated with advanced liver disease. Hypercalcemia (increased serum calcium) may be seen in conditions like hyperparathyroidism, certain cancers, or excessive vitamin D intake, but it is not a common finding in liver disease.

Choice B reason: Decreased serum ammonia is also not associated with advanced liver disease. In fact, patients with liver disease often have increased serum ammonia levels due to the liver's inability to effectively detoxify ammonia into urea. Elevated ammonia can lead to hepatic encephalopathy, a serious complication of liver disease.

Choice C reason: Increased ALT and AST are common laboratory findings in advanced liver disease. These liver enzymes, alanine aminotransferase (ALT) and aspartate aminotransferase (AST), are released into the bloodstream when liver cells are damaged or inflamed. Elevated levels indicate liver injury or dysfunction and are often used to assess the extent of liver disease.

Choice D reason: Decreased albumin is a typical finding in advanced liver disease. Albumin is a protein produced by the liver, and its levels drop when the liver is no longer able to synthesize it effectively. Low albumin levels can lead to edema and ascites due to decreased oncotic pressure in the blood vessels.

Choice E reason: Elevated bilirubin is expected in advanced liver disease. Bilirubin is a byproduct of red blood cell breakdown that is normally processed and excreted by the liver. When liver function is impaired, bilirubin accumulates in the blood, leading to jaundice, characterized by yellowing of the skin and eyes.

Choice F reason: Elevated prothrombin time (PT) is a common finding in advanced liver disease. The liver produces clotting factors necessary for blood coagulation, and when it is damaged, these factors are not produced adequately, leading to prolonged PT. This indicates a higher risk of bleeding and impaired clotting function.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client in acute respiratory failure who is receiving mechanical ventilation. Which of the following assessments is the best method to determine the effectiveness of the current treatments?

Correct Answer is A

Explanation

The nurse is caring for a patient admitted with advanced liver disease. Which laboratory result(s) would the nurse expect? Select all that apply.

Correct Answer is ["C","D","E","F"]

Explanation

A nurse is caring for a client who has a C4 spinal cord injury. Which of the following should the nurse recognize the client as being at the greatest risk for?

The nurse is caring for a newly admitted patient with sepsis and has received orders from the physician. What order should the nurse implement first?

A nurse cares for a patient recovering from mechanical valve replacement surgery. The patient asks, "Why will I need to take anticoagulants for the rest of my life?" What is the best response by the nurse?

The nurse assesses a patient who experienced a spinal cord injury at the T5 level 24 hours ago. Assessment findings are:Temp: 99.0°FHR: 46 beats/minBP: 78/52 mmHgRR: 20 breaths/minSaO2: 94% on 2L NCWhich of the following interventions should the nurse anticipate?

Which client should the telemetry nurse assess first after receiving the a.m. shift report?

A nurse is caring for a postoperative 70-kg patient who had major blood loss during surgery and now has acute kidney injury. The patient does not have signs of fluid overload. Which intervention would be most effective as a fluid challenge to promote kidney perfusion?

What does the nurse expect the healthcare provider to prescribe when a post-kidney transplant client develops oliguria, elevated temperature of 37.8°C, increased blood pressure, and signs of fluid retention 12 days after the surgery?

The nurse is instructing the client with chronic kidney disease (CKD) to maintain adequate nutritional intake. Which diet would be most appropriate?