A client who is admitted with an acute coronary syndrome (ACS) receives eptifibatide, a glycoprotein (GP) (IB IIIA. inhibitor. Which assessment finding places the client at greatest risk?

Unresponsive to painful stimuli.

Presence of hematemesis.

Incontinent with blood in urine.

Blood pressure of 100/60 mm Hg.

Answer and Explanation

The Correct Answer is B

A. Unresponsiveness to painful stimuli indicates a potential neurological issue but does not directly correlate with the risk of bleeding associated with eptifibatide use.

B. Hematemesis indicates gastrointestinal bleeding, which is a significant concern in patients on eptifibatide, as it increases the risk of serious bleeding complications.

C. Blood in urine (hematuria) can indicate a urinary tract issue or bleeding but is less critical than gastrointestinal bleeding in this context.

D. A blood pressure of 100/60 mm Hg may indicate some degree of hypotension but is not as urgent as identifying active bleeding.

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Correct Answer is D

Explanation

A. An adult nurse practitioner may provide care but is not primarily responsible for coordinating the overall plan of care.

B. A risk management nurse focuses on minimizing risk and liability rather than direct patient care coordination.

C. A neurology unit supervisor may oversee neurological cases but is not specifically involved in case management.

D. The nurse case manager plays a critical role in coordinating the client’s care across various services and ensuring continuity of care, especially for complex cases like spinal cord injuries.

A. Note the presence of an auscultatory gap. B. Reposition the stethoscope over the brachial artery. C. Re-inflate the cuff to a higher number. D. Continue with the blood pressure assessment.

Correct Answer is A

Explanation

A. Noting the presence of an auscultatory gap is essential, as it may indicate that the blood pressure reading could be inaccurately low if not recognized. This helps ensure the accuracy of the blood pressure measurement.

B. Repositioning the stethoscope may be necessary if the sounds are unclear, but recognizing the potential auscultatory gap should be prioritized first.

C. Re-inflating the cuff may be appropriate if the nurse is unsure about the readings; however, identifying an auscultatory gap is the first step to ensure accurate assessment.

D. Continuing with the blood pressure assessment without acknowledging the silence followed by a Korotkoff sound may lead to misinterpretation of the blood pressure readings.

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A client who is admitted with an acute coronary syndrome (ACS) receives eptifibatide, a glycoprotein (GP) (IB IIIA. inhibitor. Which assessment finding places the client at greatest risk?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is admitted to the intensive care until (ICU) with a spinal cord injury following a motor vehicle collision. Which nurse should be contacted to coordinate the progression of the client's care?

Correct Answer is D

Explanation

After inflating a blood pressure cuff and releasing the valve, the nurse hears silence followed by a Korotkoff sound. Which action should the nurse take next?

Correct Answer is A

Explanation

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