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 B
Explanation
A. A hard, painless nodule may indicate a deformity but is not an emergency.
B. Erythema and edema at the base of the left great toe could indicate an infection, such as cellulitis, which requires immediate intervention to prevent complications.
C. Decreased response to pain discrimination suggests neuropathy, which is concerning but not immediately life-threatening.
D. Painful corns and calluses are chronic issues that need management but are not urgent.
Correct Answer is A
Explanation
A.Beginning with less sensitive questions helps establish trust and rapport with the client, making it easier to discuss more difficult topics later. This approach can make the client feel more comfortable and less threatened, thereby improving the quality of the information gathered.
B.Sharing personal values can introduce bias and potentially influence the client's responses, making the interview less objective.
C.Starting with the most difficult questions can make the client feel anxious and defensive, reducing the likelihood of obtaining honest and thorough responses.
D.Asking vague, non-specific questions can lead to ambiguous answers and fail to provide the detailed information needed for a proper assessment.
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