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 C
Explanation
Choice A rationale
Monitoring an IV infusion rate on an established schedule requires assessment skills and clinical judgement to identify and respond to potential complications. This task should be performed by a registered nurse.
Choice B rationale
Titration of oxygen to prescribed parameters is a complex task that requires advanced assessment skills and a deep understanding of the patient’s condition and response to treatment. This task should not be delegated to unlicensed assistive personnel (UAP).
Choice C rationale
Inserting a urinary catheter for an uncomplicated patient is a task that can be safely delegated to UAP who have been trained and demonstrated competence in this skill. It is a routine procedure and does not require advanced assessment or decision-making skills.
Choice D rationale
Procuring platelet products from the blood bank is a task that involves handling and transporting biological materials, which requires specific knowledge and skills. This task should not be delegated to UAP.
Correct Answer is A
Explanation
Choice A rationale
Changing the surgical dressing promptly when it becomes soiled is crucial to minimize the risk of a MRSA recurrence in the postoperative wound. A soiled dressing can become a medium for bacterial growth, including MRSA, and can potentially contaminate the wound.
Choice B rationale
Monitoring for any increase in the white blood cell count is important in detecting an infection, including a MRSA infection. However, it is not the most crucial intervention to minimize the risk of a MRSA recurrence in the postoperative wound.
Choice C rationale
Educating the family on the importance of adhering to contact precautions is important in preventing the spread of MRSA. However, it is not the most crucial intervention to minimize the risk of a MRSA recurrence in the postoperative wound.
Choice D rationale
Wearing a face mask while performing wound care can help prevent the spread of MRSA. However, it is not the most crucial intervention to minimize the risk of a MRSA recurrence in the postoperative wound.
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