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.
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Related Questions
Correct Answer is ["82.5"]
Explanation
The general rule of thumb for urine output is 0.5 mL/kg/hour.
Step 1: Convert the patient's weight from pounds to kilograms.
We know that 1 kg = 2.2 lbs.
So, we have:
363 lbs ÷ 2.2 = 165 kg (rounded to the nearest whole number)
Step 2: Calculate the urine output using the rule of 0.5 mL/kg/hour. So, we have:
165 kg × 0.5 mL/kg/hour = 82.5 mL/hour
Correct Answer is D
Explanation
Choice A reason: Painful and red-tinged urination could be related to kidney stones but is not directly relevant to the preparation for an intravenous pyelogram.
Choice B reason: The end of the menstrual period is not typically relevant to the preparation for an intravenous pyelogram.
Choice C reason: Drinking fluids is generally encouraged but does not need to be reported unless it is restricted before the procedure.
Choice D reason: The client's allergy to shellfish is important to report because the contrast dye used in an intravenous pyelogram may contain iodine, which can cause a reaction in people with shellfish allergies.
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