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 D
Explanation
Choice A reason: Placing suction equipment at the bedside is a preparatory measure but not a preventive intervention for pulmonary complications.
Choice B reason: Performing ROM exercises is beneficial for overall mobility but does not directly prevent pulmonary complications.
Choice C reason: Administering an expectorant may help clear secretions but is not the primary preventive measure for pulmonary complications.
Choice D reason: Encouraging the use of incentive spirometry is a proven intervention to prevent pulmonary complications by promoting lung expansion and preventing atelectasis, especially in patients with a history of smoking.
Correct Answer is B
Explanation
Choice A reason: Screening for metastasis is not typically necessary for BCC because it rarely metastasizes.
Choice B reason: Minimizing sun exposure is crucial in reducing the risk for future BCC, as UV radiation is a significant risk factor.
Choice C reason: Watchful waiting is not a standard treatment plan for BCC; treatment usually involves removal of the lesion.
Choice D reason: Low-dose systemic chemotherapy is generally not used to treat BCC; local treatments such as surgery or topical medications are preferred.
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