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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. This task typically requires a more advanced level of clinical judgment and assessment skills, which are usually beyond the scope of practice for a PN and should be conducted by a Registered Nurse (RN).
B. Removing discontinued peripheral IV catheters is a task that falls within the scope of practice for a Practical Nurse (PN). It does not require the advanced assessment skills or judgment that some other tasks might require.
C. This involves critical thinking and clinical decision-making that are responsibilities typically reserved for an RN, as it requires integrating new information and adjusting care plans based on ongoing assessments.
D. While PNs can perform certain types of wound care, initiating sterile wound care for surgical clients often requires the advanced knowledge and assessment skills of an RN, particularly if the wound care involves evaluating surgical site integrity and potential complications.

A. Respond to the code. B. Call for an assistant C. Finish the procedure. D. Close the room door.

Correct Answer is A

Explanation

A. A code blue indicates a life-threatening emergency. The nurse's primary responsibility is to attend to the collapsing client immediately. The PICC removal can be completed later.

B. Calling for an assistant allows the nurse to ensure the PICC removal is completed safely while also responding to the emergency situation.
C. Finishing the procedure would delay the response to the code, potentially compromising the care of the client experiencing the emergency.
D. Closing the room door is not relevant to managing either situation safely.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After receiving a change of shift report for clients on a medical surgical unit, which activity should the nurse delegate to the practical nurse (PN)?

Correct Answer is B

Explanation

The nurse initiates the procedure to remove a client's peripherally inserted central catheter (PICC) when a code blue is called for another client in the unit who collapsed in the hallway while ambulating with the unlicensed assistive personnel (UAP). Which action should the nurse take?

Correct Answer is A

Explanation

The charge nurse is making assignments for one practical nurse (PN) and three registered nurses (RN) who are caring for neurologically compromised clients. Which client with which change in status is best to assign to the PN?

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Exhibits What goal(s) should the nurse prioritize in the care plan for the client while in the emergency department? Select all that apply.

Patient Data Exhibits The healthcare provider has obtained the arterial blood gas and chest X-ray results. New prescriptions have been entered in the client's electronic health record. Nursing Action: Indicated/ Contraindicated

Exhibits The nurse is caring for the client. Which of the following assessment findings should the nurse prioritize?