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 A
Explanation
Choice A reason: A healthy stoma should be beefy red and moist, indicating good blood supply and hydration.
Choice B reason: A dusky maroon color could indicate compromised blood supply or ischemia.
Choice C reason: A pale and pink stoma may suggest anemia or reduced blood flow.
Choice D reason: A stoma that is pink and dry could be dehydrated, which is not ideal.
Correct Answer is C
Explanation
Choice A reason (acute renal failure): Patients recovering from acute renal failure are not typically restricted to only vegetable proteins. Protein needs can vary based on the individual's condition and treatment plan.
Choice B reason (acute renal failure): Fluid intake recommendations for patients recovering from acute renal failure depend on their current kidney function and fluid balance status. A blanket restriction to 1500 mL or less per day may not be appropriate for all patients.
Choice C reason (acute renal failure): Avoiding nephrotoxic drugs is crucial for patients recovering from acute renal failure to prevent further kidney damage.
Choice D reason (acute renal failure): Self-catheterization for residual urine is not a standard recommendation for all patients recovering from acute renal failure. This would be specific to patients with urinary retention issues.
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