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 information that the nurse should obtain from the client first is: Reason for taking the aspirin.

It is important to first understand why the client was taking aspirin in order to determine the potential implications of switching to ibuprofen. Aspirin and ibuprofen are both nonsteroidal anti-inflammatory drugs (NSAIDs), but they have different indications and effects. Aspirin is commonly used for its antiplatelet properties to reduce the risk of heart attacks and strokes, while ibuprofen is primarily used for its analgesic and anti-inflammatory properties.

By understanding the reason for taking aspirin, the nurse can assess if the client was using it for its antiplatelet effects, which is important information to consider for the client's overall health and well-being.

Once the reason for taking aspirin is determined, the nurse can proceed to inquire about the other relevant information, such as the dosage of ibuprofen taken, presence of gastric pain, and amount of pain control. These details will help in assessing the client's current medication regimen, potential side effects or complications, and overall pain management.

A. Send the UAP to be fitted for a particulate filter mask immediately so she can provide care to this client. B. Advise the UAP to wear a standard face mask to obtain vital signs, and then get fitted for a filter mask before providing personal care. C. Instruct the DAP that a standard face mask is sufficient to be able to provide care for the assigned client. D. Before changing assignments, determine which staff members have fitted particulate filter masks.

Correct Answer is C

Explanation

A) This option is unnecessary because droplet precautions do not require a particulate filter mask. Particulate filter masks are needed for airborne precautions. Sending the UAP for fitting delays care without providing additional safety benefits for droplet precautions.

B) While a standard face mask is appropriate for droplet precautions, the part about getting fitted for a filter mask is unnecessary. It implies that a particulate filter mask is needed, which it is not for droplet precautions. This option also incorrectly suggests that vital signs can be obtained with a standard mask, but personal care requires a particulate filter mask, which is not accurate.

C) Droplet precautions require the use of a standard face mask, not a particulate filter mask (such as an N95 respirator). Particulate filter masks are required for airborne precautions, which are necessary for diseases like tuberculosis, measles, or chickenpox. For droplet precautions, a standard surgical mask is adequate to prevent the transmission of infections like influenza. Thus, the UAP can safely provide care to the client with flu-like symptoms by wearing a standard face mask.

D) This option is unnecessary because a particulate filter mask is not required for droplet precautions. Changing assignments based on this criterion is not needed and could disrupt the workflow without enhancing safety. The focus should be on ensuring staff understand and use the appropriate PPE for droplet precautions.

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who reports running out of aspirin 1 week ago and taking ibuprofen as a replacement. Which information should the nurse obtain from the client first?

Correct Answer is A

Explanation

An unlicensed assistive personnel (UAP) is assigned to a client with flu-like symptoms who has been placed on droplet precautions. The UAP requests a change in assignment, stating she has not yet been fitted for a particulate filter mask. Which action should the nurse take?

Correct Answer is C

Explanation

A client who is having gastrointestinal (GI) difficulties is undergoing diagnostic procedures. The client asks the nurse about the difference between ulcerative colitis and Crohn's disease. Which information should the nurse offer?

An older client with Alzheimer's disease is confused and asking the nurse to call their mother who is deceased. Which nonpharmacological intervention should the nurse implement?

A client with leukemia who is receiving myelosuppressive chemotherapy has a platelet count of 25,000/mm3 (25 x 109/L). Which intervention is most important for the nurse to include in this client's plan of care? Reference Range: Platelet Count [150,000 to 400,000/mm3 (156 400 x 109/L)]

The nurse discovers that an older client with no history of cardiac or renal disease has an elevated serum magnesium level. To further investigate the cause of this electrolyte imbalance, what information is most important for the nurse to obtain from the client's medical history?