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 A
Explanation
Choice A rationale
Uterine atony refers to a condition where the uterus fails to contract sufficiently during and after childbirth. This lack of contraction can lead to excessive bleeding, also known as postpartum hemorrhage. This is because the contractions of the uterus after delivery help to compress the blood vessels and prevent bleeding. Therefore, uterine atony can cause a patient to hemorrhage.
Choice B rationale
Wound dehiscence refers to a surgical complication where an incision reopens either internally or externally. It can cause pain, infection, and organ protrusion. However, it is not directly associated with hemorrhaging.
Choice C rationale
Infection refers to the invasion of tissues by pathogens, their multiplication, and the reaction of host tissues to the infectious agent and the toxins they produce. While severe infections can lead to sepsis and disseminated intravascular coagulation, which can cause bleeding, they do not directly cause hemorrhaging.
Choice D rationale
Hemorrhage is a symptom, not a condition. It refers to excessive bleeding which can occur due to various conditions, including uterine atony.
Correct Answer is C
Explanation
Choice A rationale
Auscultating an area six inches below the umbilicus would not provide the most useful data when assessing for possible urinary retention. Auscultation is typically used to assess bowel sounds and not typically used in the assessment of urinary retention.
Choice B rationale
Observing the appearance of the patient’s urine can provide some information about the patient’s hydration status and kidney function, but it would not be the most useful technique for assessing urinary retention.
Choice C rationale
Palpating the area above the pubic symphysis can provide useful data when assessing for possible urinary retention. If the bladder is distended due to urinary retention, it may be palpable in this area.
Choice D rationale
Measuring the girth of the patient’s lower abdomen is not typically used as a method to assess for urinary retention. While an increase in abdominal girth can occur with urinary retention, it is not the most direct or reliable method for assessment.
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