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

Answer and Explanation

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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Correct Answer is A

Explanation

Choice A reason (client care): A client reporting shortness of breath may be experiencing a life-threatening situation that aligns with the ABCs (Airway, Breathing, Circulation) of patient prioritization. This client requires immediate assessment and intervention.

Choice B reason (client care): While discharge is important, it does not take precedence over a client with potential respiratory distress.

Choice C reason (client care): A client who received pain medication 30 minutes ago is likely stable and can be seen after more urgent cases are addressed.

Choice D reason (client care): A client waiting for an abdominal x-ray is not a priority over a client with respiratory issues.

A. Enhance the formation of granulation tissue. B. Ensure brisk bleeding from the sites so ﬂuid volume status can be maintained. C. Ensure the return of distal pulses. D. Decrease edema formation.

Correct Answer is C

Explanation

Choice A reason: Enhancing the formation of granulation tissue is not the immediate expected outcome of an escharotomy.

Choice B reason: Ensuring brisk bleeding is not the goal; minimal bleeding is expected, and it should be controlled to maintain ﬂuid volume status.

Choice C reason: Ensuring the return of distal pulses is the expected outcome of an escharotomy, as it relieves pressure and restores circulation to the aﬀected limbs.

Choice D reason: Decreasing edema formation is a benefit of the procedure but not the primary expected outcome.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is prioritizing client care after receiving a change-of-shift report. Which of the following clients should the nurse plan to see first?

Correct Answer is A

Explanation

The nurse is preparing to assist the burn surgeon in performing an escharotomy for a patient who has full-thickness circumferential burns that resulted in compartment syndrome. The nurse understands that the expected outcome of this procedure is to:

Correct Answer is C

Explanation

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