Nokea
At 9:00 pm, you admit a 63-year-old with a diagnosis of acute myocardial infarction (AMI) to the ED. The physician is considering the use of fibrinolytic therapy with tissue plasminogen activator (tPA, alteplase). Which information is most important to communicate to the physician?
- A. The patient was treated with alteplase about 8 months ago.
- B. The patient takes famotidine (Pepcid) for esophageal reflux.
- C. The patient has T wave inversions on the 12-lead ECG.
- D. The patient has had continuous chest pain since 1:00 pM.
Correct Answer: D
Rationale: Continuous chest pain indicates ongoing ischemia, making the patient a candidate for fibrinolytic therapy within the therapeutic window.
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In auscultating over a peripheral artery, what sound would suggest obstruction of the artery?
- A. Dullness
- B. Tympany
- C. Bruit
- D. Vibrations
Correct Answer: C
Rationale: A bruit is an abnormal sound heard over an artery due to turbulent blood flow, often indicating partial obstruction.
The client is on enoxaparin (Lovenox) for DVT prophylaxis. What is the most important lab value to monitor?
- A. Platelet count
- B. PT/INR
- C. aPTT
- D. Hemoglobin
Correct Answer: A
Rationale: The correct answer is A: Platelet count. Enoxaparin is a low molecular weight heparin that can cause thrombocytopenia, a potentially serious side effect. Monitoring platelet count is crucial to detect any decrease, as it may increase the risk of bleeding. PT/INR and aPTT are used to monitor warfarin and heparin, respectively, not enoxaparin. Hemoglobin monitoring is important for anemia but not the most crucial lab value in this scenario.
The client is on nitroglycerin and reports chest pain. What is the nurse's priority action?
- A. Administer nitroglycerin as ordered.
- B. Administer morphine as ordered.
- C. Administer aspirin as ordered.
- D. Notify the healthcare provider immediately.
Correct Answer: D
Rationale: The correct answer is D: Notify the healthcare provider immediately. When a client on nitroglycerin reports chest pain, it could indicate a worsening condition or potential myocardial infarction. The nurse's priority is to notify the healthcare provider promptly for further assessment and intervention. Administering nitroglycerin (choice A) may not address the underlying cause of the chest pain. Administering morphine (choice B) may mask symptoms and delay appropriate treatment. Administering aspirin (choice C) is important in chest pain management but does not take priority over notifying the healthcare provider for further evaluation and guidance.
Which condition is caused by a bacterium that primarily affects the lungs but can spread to other parts of the body?
- A. Tuberculosis
- B. Pneumonia
- C. Legionnaires' disease
- D. Histoplasmosis
Correct Answer: A
Rationale: The correct answer is A: Tuberculosis. Tuberculosis is caused by the bacterium Mycobacterium tuberculosis, which primarily affects the lungs but can spread to other parts of the body through the bloodstream or lymphatic system. This bacterium specifically targets the lungs, leading to symptoms such as coughing, chest pain, and difficulty breathing. In contrast, Pneumonia (B) is commonly caused by viruses, bacteria, or fungi affecting the lungs but doesn't specifically spread to other body parts like TB. Legionnaires' disease (C) is caused by Legionella bacteria and primarily affects the lungs, but it does not have the same capability to spread to other body parts like TB. Histoplasmosis (D) is a fungal infection that primarily affects the lungs but does not spread to other parts of the body in the same way as tuberculosis.
The client on amiodarone reports shortness of breath. What is the nurse's best response?
- A. Notify the healthcare provider immediately.
- B. Reassure the client that this is a common side effect.
- C. Instruct the client to monitor their symptoms at home.
- D. Suggest the client reduce physical activity.
Correct Answer: A
Rationale: The correct answer is A: Notify the healthcare provider immediately. Shortness of breath in a client on amiodarone can indicate a serious side effect such as pulmonary toxicity or interstitial lung disease. The nurse should prioritize the client's safety by promptly informing the healthcare provider for further evaluation and management. This is crucial to prevent potential harm or worsening of the condition.
Summary:
- Choice B is incorrect because shortness of breath with amiodarone is not a common side effect to be reassured about.
- Choice C is incorrect as monitoring symptoms at home may delay necessary medical intervention.
- Choice D is incorrect as reducing physical activity does not address the potential serious side effect of amiodarone.