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 D

Explanation

A. While monitoring troponin levels is important for diagnosing myocardial infarction, immediate relief of chest pressure and shortness of breath is a higher priority.
B. Placing an indwelling urinary catheter and measuring intake and output is not the immediate priority for managing acute chest pain and potential myocardial ischemia.
C. Counting premature ventricular contractions is useful but not the most immediate action in managing acute chest pressure and shortness of breath.
D. Recording the pain score and administering sublingual nitroglycerine addresses the acute symptoms of chest pressure and shortness of breath, aiming to relieve myocardial ischemia.

A. Determine if the client has recently experienced a fall. B. Instruct the adult child to check the client's temperature. C. Ask if the client is experiencing any pain with urination. D. Encourage increased intake of high protein foods. E. Review the client's current food and medication allergies.

Correct Answer is ["A","B","C","E"]

Explanation

A. Falls can lead to head injuries or subdural hematomas, which can cause confusion in older adults. It is important to assess for recent trauma as a possible cause of the confusion.
B. An elevated temperature can indicate an infection, such as a urinary tract infection (UTI) or pneumonia, which are common causes of acute confusion in older adults.
C. Pain with urination is a symptom of a UTI, which can lead to confusion, especially in elderly patients with Parkinson's disease.
D. While maintaining adequate nutrition is important, increasing protein intake does not directly address the sudden onset of confusion.
E. New medications or allergic reactions can lead to confusion. A medication interaction or an allergic reaction to a new food could be a contributing factor.

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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

A client who underwent cardiac stent placement four days ago arrives to the emergency department reporting a sudden onset of chest pressure and shortness of breath. Which action should the nurse take next?

Correct Answer is D

Explanation

The adult child of an older adult client who has Parkinson's disease, calls the clinic and reports that the client has been confused for the past week. What action(s) should the nurse take? Select all that apply.

Correct Answer is ["A","B","C","E"]

Explanation

What 2 orders should the nurse complete first?

Patient's data Exhibits The nurse obtains verbal handoff from the outpatient clinic nurse, reviews the electronic health record, and completes an initial assessment including vital signs. Which assessment findings require follow up by the nurse? Select all that apply.

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

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?

Patient Data Exhibits The healthcare provider has assessed the client and completes initial prescriptions. Which three interventions should the nurse prioritize for this client?

The nurse is managing the care of a client with Cushing's syndrome. What intervention(s) should the nurse delegate to the unlicensed assistive personnel (UAP)? Select all that apply.