The nurse receives a patient from the emergency department following administration of a fibrinolytic medication, TPA, for a large anterior wall myocardial infarction. The priority assessment for this patient would be which of the following?
Urine output
Vital signs
Name of the patient's dog
Neurological status
The Correct Answer is D
Choice A reason: Urine output is important but not the priority after administration of fibrinolytic medication.
Choice B reason: Vital signs are routinely monitored but the priority is assessing for any signs of complications from the medication, such as bleeding or stroke.
Choice C reason: The name of the patient's dog is irrelevant to the patient's medical care and assessment.
Choice D reason: Neurological status is the priority to monitor for signs of intracranial hemorrhage, a potential complication of fibrinolytic therapy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Packed RBCs should be transfused as soon as possible once the nurse has prepared everything necessary for the transfusion.
Choice B reason: Waiting 2 hours after obtaining the blood is not necessary and could delay needed treatment.
Choice C reason: The client's mealtime should not delay the transfusion of blood, which is a time-sensitive medical treatment.
Choice D reason: While the client's readiness is important, it should not unduly delay the transfusion if the client is medically stable and the transfusion is necessary.
Correct Answer is B
Explanation
Choice A reason: Dabigatran does not specifically slow the ventricular response; medications like beta-blockers are typically used for rate control in atrial fibrillation.
Choice B reason: Dabigatran is an anticoagulant that reduces the risk of stroke and systemic embolism in patients with nonvalvular atrial fibrillation by preventing clot formation.
Choice C reason: Dabigatran does not convert atrial fibrillation to sinus rhythm; that would be the role of antiarrhythmic drugs or procedures like cardioversion.
Choice D reason: While dabigatran can prevent clots from forming, it is not used to dissolve existing clots; thrombolytic agents are used for that purpose.
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