A patient is admitted to the emergency department and diagnosed as having an ST-segment-elevation myocardial infarction (STEMI). Which question would the nurse ask to determine whether the patient is a candidate for thrombolytic therapy?.
"Did you take aspirin today?".
"Do you have any allergies?".
"Can you rate the pain on a 0 to 10 scale?".
"What time did your pain begin?". .
The Correct Answer is D
Choice A rationale:
While aspirin is often given to patients with suspected myocardial infarction, asking if the patient took aspirin does not help determine the timing of the onset of symptoms.
Choice B rationale:
Knowing the patient’s allergies is important for medication safety, but it does not help determine eligibility for thrombolytic therapy.
Choice C rationale:
Rating the pain on a scale helps assess the severity of the pain, but it does not provide information about the timing of the onset of symptoms.
Choice D rationale:
The time of pain onset is crucial in determining eligibility for thrombolytic therapy. Thrombolytic therapy is most effective when given within a certain time frame from the onset of symptoms.
So, the correct answer is D, after analyzing all choices.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
The right upper-sternal border is not the best place to hear a murmur typical of mitral regurgitation.
Choice B rationale:
The left upper-sternal border is not the best place to hear a murmur typical of mitral regurgitation.
Choice C rationale:
The left lower-sternal border is not the best place to hear a murmur typical of mitral regurgitation.
Choice D rationale:
The apex of the heart is the best place to hear a murmur typical of mitral regurgitation. This is where the sound will be most audible.
So, the correct answer is Choice D, after analyzing all choices.
Correct Answer is B
Explanation
Choice A rationale:
A weight increase from 120 pounds to 122 pounds over 3 days is within the normal fluctuation range.
Choice B rationale:
A serum potassium level of 3.0 mEq/L after 1 week of therapy is concerning because it’s below the normal range (3.5-5.0 mEq/L)171819. This could indicate hypokalemia, which can cause serious complications if left untreated.
Choice C rationale:
A palpable liver edge 2 cm below the ribs on the right side could suggest an abnormality such as an enlarged liver.
Choice D rationale:
The presence of 1+ to 2+ edema in the feet and ankles could indicate conditions like heart failure or venous insufficiency.
So, the correct answer is Choice B, after analyzing all choices.
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