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 B
Explanation
Choice A reason : Maintenance chemotherapy is not typically used to maintain remission in Hodgkin's lymphoma after successful treatment.
Choice B reason : Follow-up appointments are crucial for monitoring any signs of recurrence or secondary malignancies, as well as managing long-term effects of treatment.
Choice C reason : The potential impact of chemotherapy on fertility is an important topic, especially for younger patients, but may not be as relevant for a 55-year-old woman.
Choice D reason : Addressing symptoms like pruritus, which can persist after treatment, is important for patient comfort and quality of life.
Correct Answer is C
Explanation
Choice A reason: Respiratory Acidosis is characterized by a low pH and a high PCO2, which is not the case here.
Choice B reason: Respiratory Alkalosis would involve a high pH and a low PCO2, which is not consistent with the patient's PCO2 level.
Choice C reason: Metabolic Alkalosis is indicated by a high pH and a high HCO3, which matches the patient's blood gas values.
Choice D reason: Metabolic Acidosis would show a low pH and a low HCO3, which is the opposite of this patient's presentation.
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