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 C
Explanation
Choice A reason: Taking several deep breaths is not specifically related to the preparation for a renal system physical assessment. Deep breaths are more commonly associated with lung examination or to help the patient relax.
Choice B reason: Drinking several glasses of water before a renal assessment could potentially fill the bladder, which might interfere with palpation of the kidneys and make it uncomfortable for the patient.
Choice C reason: Emptying the bladder is the correct action before a renal system physical assessment. It allows for better palpation of the kidneys and other structures without the discomfort of a full bladder. It also prevents the possibility of the patient urinating involuntarily during the examination due to a full bladder.
Choice D reason: Providing a urine sample might be part of the overall renal assessment, but it is not necessary to do so immediately before the physical examination of the renal system. The sample can be collected at any time before or after the physical examination.
Correct Answer is B
Explanation
Choice A reason: Dumping syndrome is not commonly associated with dysphagia post-stroke.
Choice B reason: Aspiration is a significant risk for patients with dysphagia following a stroke and should be closely monitored to prevent complications like aspiration pneumonia.
Choice C reason: Gastroesophageal reflux disease may occur but is not the most immediate concern for stroke patients with dysphagia.
Choice D reason: Peptic ulcer disease is not directly related to dysphagia and is less likely to be an immediate complication post-stroke.
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