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","C","D","E"]
Explanation
A. Changing the glucose monitoring device is unlikely to address the root cause of the elevated blood sugars.
B. Some asthma medications, such as corticosteroids, can increase blood glucose levels. Evaluating these medications is essential.
C. Incorrect technique in monitoring blood glucose can lead to inaccurate readings.
Having the client demonstrate the technique can identify any errors.
D. Ensuring that a new insulin needle is used for each administration is important to prevent infection and ensure proper dosage.
E. Understanding the client’s daily routine, including diet, exercise, and stress levels, can provide insight into factors affecting blood glucose control.
Correct Answer is D
Explanation
A. Pink-tinged hematuria is expected after the procedure, but reporting should be directed at increased bleeding or other signs of complications.
B. While some activity restrictions are necessary, a complete restriction of all physical activities is generally not advised and can lead to other complications like blood clots or decreased mobility.
C. An incentive spirometer is typically used to prevent respiratory complications post-surgery, but it is not specifically related to nephrolithotomy procedures.
D. Monitoring the urinary output is crucial because decreased output can indicate a blockage or other complications related to the nephrostomy tube.
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