A nurse receives report on four clients at the beginning of the shift. Which of the following clients should the nurse place priority on assessing first?

A client who had a myocardial infarction two days ago, and complains of soft stools after taking docusate sodium.

A client being treated for thrombotic thrombocytopenic purpura (TTP) who has had 120 mL of urine output in the last 12 hours.

A client who was admitted for premature atrial contractions (PACS) and whose most recent blood pressure is 148/89.

A client receiving furosemide for heart failure whose daily weight shows that he has lost 0.5 kg since yesterday.

Answer and Explanation

The Correct Answer is B

A. While soft stools after taking docusate sodium is noteworthy, it is not immediately life-threatening and does not require urgent intervention.
B. Oliguria (low urine output) in a client with TTP is concerning because it may indicate acute kidney injury or worsening of the condition, requiring immediate assessment and intervention.
C. An elevated blood pressure in a client with PACs is important but not as critical as potential kidney dysfunction in the TTP patient.
D. A weight loss of 0.5 kg in a client with heart failure on furosemide may be expected and does not require immediate intervention.

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Correct Answer is B

Explanation

A. Plasmapheresis in TTP aims to remove abnormal blood components, not ADAMTS-13. In fact, plasmapheresis helps replenish ADAMTS-13.
B. The primary goal of plasmapheresis in TTP is to remove large von Willebrand factor molecules that are causing platelet aggregation and clot formation.
C. Removing macrophages from the spleen is not the objective of plasmapheresis.
D. Plasmapheresis is usually performed daily until clinical and laboratory parameters improve, not just once a week.

A. NSTEMI B. Stable angina C. STEMI D. Unstable angina

Correct Answer is D

Explanation

A. NSTEMI would present with elevated troponin levels indicating myocardial injury, which is not the case here.

B. Stable angina occurs predictably with exertion and is relieved by rest or nitroglycerin.

C. STEMI is characterized by ST-elevation on the ECG and elevated troponin levels, indicating significant myocardial injury.

D. Unstable angina presents with chest pain that occurs at rest or with minimal exertion and is not predictable. The presence of T-wave inversion and normal troponin levels is consistent with this diagnosis.

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A nurse receives report on four clients at the beginning of the shift. Which of the following clients should the nurse place priority on assessing first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has been diagnosed with thrombotic thrombocytopenic purpura (TTP) and will begin plasmapheresis ment should the nurse plan to include when educating the client about this treatment?

Correct Answer is B

Explanation

Correct Answer is D

Explanation

A nurse receives report on four clients at the beginning of the shift. Which of the following clients should the nurse place priority on assessing first?

A nurse is caring for a client who has a diagnosis of immune thrombocytopenic purpura (ITP). Despite medication therapy, the client's platelets are low. Which of the following procedures would reduce the destruction of platelets for a client who has ITP?

A nurse on a telemetry unit is caring for four clients. Which of the following clients is experiencing potential manifestations of a myocardial infarction?

A client who has been diagnosed with chronic stable angina is placed on multiple medications to manage the condition. The nurse understands that the client is receiving lisinopril for which reason?

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A client is seen in the emergency department with a heart failure exacerbation due to noncompliance with medications and fluid restrictions. Which key diagnostic result should the nurse assess to determine the severity of the client's heart failure exacerbation?

A nurse on an oncology unit is preparing to administer daunorubicin to a client who has leukemia. Which action should the nurse take before administering this medication?