A patient admitted with an acute coronary syndrome (ACS) is receiving eptifibatide, a glycoprotein (GP) IIb IIIa inhibitor.
Which assessment finding poses the greatest risk to the patient?
Blood pressure of 100/60 mm Hg.
Presence of hematemesis.
Incontinence with blood in urine.
Unresponsiveness to painful stimuli.
The Correct Answer is B
Choice A rationale
A blood pressure of 100/60 mm Hg is not typically considered a risk for patients receiving eptifibatide. While eptifibatide can cause hypotension, a blood pressure of 100/60 mm Hg is within normal limits.
Choice B rationale
The presence of hematemesis, or vomiting blood, poses the greatest risk to the patient. Eptifibatide is a glycoprotein IIb/IIIa inhibitor that prevents platelets from clumping together by blocking the action of certain proteins. This can increase the risk of bleeding, including gastrointestinal bleeding, which could manifest as hematemesis.
Choice C rationale
Incontinence with blood in the urine could indicate a urinary tract infection or other urinary system issue, but it is not typically associated with the use of eptifibatide.
Choice D rationale
Unresponsiveness to painful stimuli is a serious symptom that could indicate a number of issues, including neurological damage or severe illness. However, it is not typically associated with the use of eptifibatide.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Walking at least once an hour at work can be beneficial for overall health and can contribute to maintaining energy balance. However, it may not be the most effective action for maintaining energy balance for a person who already exercises 2 to 3 times per week.
Choice B rationale
Increasing exercise intensity can help burn more calories and can contribute to maintaining energy balance. However, it’s important to note that exercise alone may not be sufficient for maintaining energy balance if not combined with a balanced diet.
Choice C rationale
Avoiding foods with high carbohydrate levels is not necessarily an effective action for maintaining energy balance. Carbohydrates are a primary source of energy for the body. While it’s important to choose complex carbohydrates over simple ones, avoiding carbohydrates altogether is not recommended.
Choice D rationale
Selecting foods that are lower in caloric density is an effective action for maintaining energy balance. Foods that are lower in caloric density, such as fruits and vegetables, can provide essential nutrients without contributing excessive calories. This can help maintain energy balance and prevent weight gain.
Correct Answer is D
Explanation
Choice A rationale
Assigning the newly hired UAP to clients who require the least complex level of care might not be the best approach. While it might seem logical to assign less complex cases to a new hire, this could limit the UAP’s opportunities for learning and growth.
Choice B rationale
Reviewing the UAP’s skills checklist and experience with the person who hired the UAP is an important step, but it might not be enough to ensure adequate care for all clients. The skills and experiences listed on a checklist might not fully reflect the UAP’s actual abilities in a real-world setting.
Choice C rationale
Asking the most experienced UAP on the team to partner with the newly hired UAP could be beneficial for mentorship and guidance. However, this might not be the most efficient use of resources, especially if the experienced UAP has to spend a significant amount of time supervising the new hire.
Choice D rationale
Assessing the newly hired UAP’s competency level by observing the UAP deliver care is the most effective way to ensure adequate care for all clients. This allows the nurse to directly evaluate the UAP’s skills and abilities in a real-world setting, and to provide immediate feedback and guidance as needed.
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