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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Showing the patient that her leg is gone does not address the immediate concern of pain management.
Choice B reason: Administering the prescribed pain medication is the first step in managing phantom pain, which is a common experience for amputees.
Choice C reason: While it is important to validate the patient's experience of pain, the first action should be to address the pain medically.
Choice D reason: Telling the patient that it is not possible to feel pain in her toes is incorrect and dismissive of the phenomenon of phantom pain.
Correct Answer is D
Explanation
Choice A reason: Aspirin can irritate the stomach lining and increase acid reflux, worsening GERD symptoms. It is generally not recommended without consulting a healthcare provider.
Choice B reason : Mercury content in seafood is not directly linked to GERD. This statement is misleading and does not address known risk factors for GERD.
Choice C reason : Lying down after eating can indeed increase the onset of GERD as it allows stomach contents to flow back into the esophagus more easily.
Choice D reason : Alcohol and caffeine can relax the lower esophageal sphincter, allowing stomach acid to rise into the esophagus and worsen GERD symptoms. Therefore, it is advisable to avoid or reduce their intake.
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