The nurse receives a patient from the emergency department following administration of a fibrinolytic medication, TPA, for a large anterior wall myocardial infarction. The priority assessment for this patient would be which of the following?
Urine output
Vital signs
Name of the patient's dog
Neurological status
The Correct Answer is D
Choice A reason: Urine output is important but not the priority after administration of fibrinolytic medication.
Choice B reason: Vital signs are routinely monitored but the priority is assessing for any signs of complications from the medication, such as bleeding or stroke.
Choice C reason: The name of the patient's dog is irrelevant to the patient's medical care and assessment.
Choice D reason: Neurological status is the priority to monitor for signs of intracranial hemorrhage, a potential complication of fibrinolytic therapy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Requesting a job that requires sitting all day does not reflect an understanding of correct body mechanics or how to manage chronic back pain through activity.
Choice B reason: Beginning exercises to strengthen the lower back indicates that the patient understands the importance of muscle strength in supporting the spine and preventing back pain.
Choice C reason: Keeping the back straight while lifting is important, but the statement about lifting "heavy objects above my waist" suggests a misunderstanding, as lifting objects above the waist increases the risk of back injury.
Choice D reason: Sleeping with knees and back extended is not recommended for preventing back pain. It is better to sleep with knees slightly bent to maintain the natural curve of the spine.
Correct Answer is A
Explanation
Choice A reason: Asking about numbness or tingling is important to rule out neurological issues that could be causing the neck pain.
Choice B reason: While heat and cold therapy may provide relief, it is not the first action to take before assessing the cause of the pain.
Choice C reason: Providing information about exercises is helpful but should come after an initial assessment.
Choice D reason: Teaching about NSAIDs is part of pain management but should follow an assessment of symptoms and potential causes.
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