A client with an acute myocardial infarction (MI) is given a thrombolytic medication, aspirin, and IV heparin in the emergency department. Which finding indicates the client is having a satisfactory response?
Activated partial thromboplastin time (aPTT) is 2 times the control value.
S3 heart sounds are present with auscultation.
Cardiac tracing shows 1.2 mm wide Q waves half the height of the complex.
Guaiac test of the stools is positive.
The Correct Answer is A
A. An aPTT that is 2 times the control value indicates that the heparin is effectively anticoagulating the blood, which is a desired outcome in managing MI to prevent clot formation.
B. S3 heart sounds can indicate heart failure and are not a sign of a satisfactory response to MI treatment.
C. Wide Q waves indicate a previous infarction but do not reflect the immediate effectiveness of the treatment.
D. A positive guaiac test indicates gastrointestinal bleeding, which is a potential complication rather than a satisfactory response.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. A nasogastric tube prescribed for low intermittent suction is intended to remove gastric contents and prevent accumulation of air and secretions. If the suction is turned off gastric contents can accumulate, risk of vomiting and aspiration increases, especially in a sedated client with a reduced gag reflex, abdominal distention and discomfort may occur, and postoperative complications can develop quickly. Because aspiration directly threatens airway and breathing, this finding requires immediate intervention.
B. A Hemovac drain must be compressed to maintain negative pressure. If not compressed, drainage may not be effective, but this is not immediately life-threatening compared to airway/aspiration risk
C. An almost completely full urinary catheter drainage bag requires attention but does not pose an immediate threat to the client's condition.
D. Oxygen up to 4 L/min via nasal cannula typically does not require humidification in most clinical settings. May cause mild dryness but is not an immediate threat to airway or life.
Correct Answer is B
Explanation
A. Ensuring that someone stays with the client for 24 hours is important for immediate postoperative care but does not directly ensure compliance with self-care instructions.
B. The teach-back method involves asking the client to repeat in their own words the instructions you just provided. This confirms that they understand the information correctly and are able to follow it at home. For a client with hearing difficulties, this ensures that any miscommunication is identified and corrected before discharge, improving compliance and safety.
C. Speaking clearly and facing the client for lip reading is helpful for communication but does not ensure that the client fully understands and can follow the instructions.
D. Providingwritten instructions for eye drop administrationis useful as a supplement, but written instructions may not guarantee understanding, especially if the client has visual limitations or confusion.
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