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

Answer and Explanation

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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Correct Answer is C

Explanation

Choice A reason : While maintaining a stable ECG rhythm is important, it is not the highest priority. The primary concern is to address life-threatening complications.

Choice B reason : Educating the patient about the causes and eﬀects of coronary heart disease (CHD) or coronary artery disease (CAD) is important for long-term management but is not the immediate priority during acute care.

Choice C reason : Adequate relief of pain is the highest priority in the care of a patient with AMI. Pain is an indicator of ongoing ischemia and can increase the workload of the heart, thereby worsening the condition.

Choice D reason (AMI): While bedrest is part of the care plan, it is not the highest priority compared to pain relief, which has direct implications on the patient's immediate physiological status.

A. 0.04-0.20 seconds B. 0.12-0.20 seconds C. Less than half the R-to-R ratio D. 0.08-0.10 seconds

Correct Answer is B

Explanation

Choice A reason: A PR interval of 0.04-0.20 seconds is too broad and includes values that are both below and above the normal range.

Choice B reason: A PR interval of 0.12-0.20 seconds is the established normal range for adults, reﬂecting proper conduction through the AV node.

Choice C reason: The PR interval being less than half the R-to-R ratio is not a standard measurement for PR intervals and does not provide a specific range.

Choice D reason: A PR interval of 0.08-0.10 seconds is below the normal range and may suggest pre-excitation or an AV nodal (junctional) rhythm.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

In planning care for a patient with acute myocardial infarction (AMI), which of the following should the nurse identify as the highest priority goal of care?

Correct Answer is C

Explanation

The normal PR interval is:

Correct Answer is B

Explanation

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