Following a cardiac catheterization and placement of a stent in the right coronary artery, the nurse administers prasugrel, a platelet inhibitor, to the client. To monitor for adverse effects from the medication, which assessment is most important for the nurse to include in this client's plan of care?

Observe the color of urine.

Assess skin turgor.

Measure body temperature.

Check for pedal edema.

Answer and Explanation

The Correct Answer is A

To monitor for adverse effects from prasugrel, a platelet inhibitor, the nurse should prioritize assessing for bleeding or abnormal bleeding tendencies. Therefore, observing the color of urine is the most important assessment among the options provided.

Changes in urine color, such as the presence of blood or dark-colored urine, can indicate internal bleeding or bleeding in the urinary tract, which can be a potential adverse effect of platelet inhibitors. It is crucial to monitor for signs of bleeding to ensure the client's safety and intervene promptly if necessary.

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Correct Answer is A

Explanation

The correct answer ischoice A.

Choice A rationale:

Having the client vocalize the instructions provided ensures that they have understood the information correctly.This method allows the nurse to confirm comprehension and clarify any misunderstandings.

Choice B rationale:

Providing written instructions for eye drop administration is helpful but does not ensure that the client understands the instructions.It is a good supplementary measure but should not be the sole method of communication.

Choice C rationale:

Speaking clearly and facing the client for lip reading is important, especially for clients with hearing impairments.However, it does not guarantee that the client has understood the instructions.

Choice D rationale:

Ensuring that someone will stay with the client for 24 hours is a good safety measure but does not directly address the client’s understanding of the discharge instructions.

A. Tell the client to discuss the medication side effects with the healthcare provider. B. Tell the client that the medication's side effects will most likely dissipate over time. C. Inform the client that gradual tapering must be used to discontinue the medication. D. Remind the client that feeling better is the therapeutic effect of the medication.

Correct Answer is C

Explanation

The correct answer is choice c. Inform the client that gradual tapering must be used to discontinue the medication.

Choice A rationale:

While discussing medication side effects with the healthcare provider is important, it does not address the immediate concern of discontinuing the medication safely. The nurse should provide guidance on the proper discontinuation process.

Choice B rationale:

Telling the client that side effects will most likely dissipate over time may not be accurate for all individuals and does not address the client’s desire to stop the medication.

Choice C rationale:

Informing the client that gradual tapering must be used to discontinue the medication is crucial. Abruptly stopping antidepressants can lead to withdrawal symptoms and a potential relapse of depression.

Choice D rationale:

Reminding the client that feeling better is the therapeutic effect of the medication is true, but it does not address the client’s concern about discontinuing the medication safely.

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Naxlex Comprehensive Predictor Exams

An older woman who has difficulty hearing is being discharged from day surgery following a cataract extraction and lens implantation. Which intervention is most important for the nurse to implement to help ensure the client's compliance with self-care?

Correct Answer is A

Explanation

Correct Answer is C

Explanation

The nurse is triaging several children as they present to the emergency room after a school bus accident. Which child requires the most immediate intervention by the nurse?

The nurse is caring for a client after a thoracentesis that drained 50 mL of clear fluid from the left lung. Which assessment finding should the nurse report to the healthcare provider immediately?

A client with cancer is admitted to the oncology unit and tells the nurse that he is in the hospital for palliative care measures. The nurse notes that the client's admission prescriptions include radiation therapy. Which action should the nurse implement?

The parent of a child born with a myelomeningocele asks the nurse, "What did I do to deserve this?" Which response is most helpful?

The nurse is assessing a 4-year-old child with eczema. The child's skin is dry and scaly, and the mother reports that the child frequently scratches the lesions on the skin to the point of causing bleeding. Which guideline is indicated for care of this child?

A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with pneumonia. Vital signs include: heart rate 122 beats/minute, respiratory rate 28 breaths/minute, and blood pressure 170/90 mmHg. Which assessment finding warrants the most immediate intervention by the nurse?