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: A healthy stoma should be beefy red and moist, indicating good blood supply and hydration.
Choice B reason: A dusky maroon color could indicate compromised blood supply or ischemia.
Choice C reason: A pale and pink stoma may suggest anemia or reduced blood flow.
Choice D reason: A stoma that is pink and dry could be dehydrated, which is not ideal.
Correct Answer is A
Explanation
Choice A reason: Pin site care is essential for a client with skeletal traction to prevent infection and ensure proper healing.
Choice B reason: A five-pound weight lifting restriction is not related to the care of a client with skeletal traction.
Choice C reason: Prone positioning is not typically recommended for clients with skeletal traction as it may interfere with the traction setup.
Choice D reason: Intermitent weights are not a standard intervention for skeletal traction, which requires consistent and controlled application of force.

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