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The nurse is interviewing a patient who might be a candidate for fibrinolytic
therapy for treatment of myocardial infarction. Why is determining the time of
symptom onset essential for decision making?
A. Fibrinolytic drugs will not dissolve clots that are older than 6 hours
B. Clots that are older than 6 hours are tightly meshed and complete
C. Tissue that is anoxic for more than 6 hours is unlikely to benefit
D. After 6 hours, the patient is more likely to have excessive bleeding - ANSWERS-
C. Tissue that is anoxic for more than 6 hours is unlikely to benefit
The home health nurse notices that new medications were prescribed for a
patient during a recent hospitalization. In addition, the patient reports taking
daily low-dose aspirin, but aspirin is not on the medication reconciliation list.
Because of the aspirin, the nurse is most likely to call the prescribing health care
provider for clarification of which type of medication?
A. Vitamin supplement
B. Platelet inhibitor
C. Antihypertensive
D. Erythrocyte stimulating agent - ANSWERS-B. Platelet inhibitor
,A patient has a suspected hematologic problem. Which instruction is the nurse
most likely to give to the UAP?
A. Record urine output for the shift
B. Take the vital signs every 2 hours
C. Assess the patient for fatigue after exertion
D. Handle the patient gently to avoid bruising - ANSWERS-D. Handle the patient
gently to avoid bruising
A patient is diagnosed with iron deficiency anemia. Which assessment finding is
the nurse most likely to observe in this patient?
A. Neck veins are distended and edema is present
B. Lower extremities show signs of phlebitis
C. Systolic blood pressure is lower than normal
D. Palpation of ribs or sternum elicits tenderness - ANSWERS-C. Systolic blood
pressure is lower than normal
An experienced nurse is supervising a new nurse who is assessing a patient with a
suspected hematologic problem. The experienced nurse would intervene if the
new nurse performed which action?
A. Palpated the edge of the liver in the right upper quandrant
B. Auscultated the heart for abnormal heart sounds or irregular rhythm
C. Used the fingertips to firmly press over the ribs or sternum
,D. Palpated the left upper quadrant to locate the enlarged spleen - ANSWERS-D.
Palpated the left upper quadrant to locate the enlarged spleen
The nurse routinely checks mental status on all patients, however, which patient
has the greatest need for frequent neurologic assessment and checks of cognitive
function?
A. Elderly patient with chronic dementia has iron deficiency anemia due to poor
diet
B. Younger female patient has low hemoglobin and hematocrit related to heavy
menses
C. Older male with alcoholism sustains head injury during an episode of
intoxication
D. Young male has fever and elevated white blood cell count related to an upper
respiratory infection - ANSWERS-C. Older male with alcoholism sustains head
injury during an episode of intoxication
The nurse notes that the patient's platelet count is 400,000/mm. What action is
the nurse most likely to take?
A. Immediately inform the health care provider because of possible spontaneous
bleeding
B. Instruct UAP to handle patient gently to minimize bruising
C. Document the result because it is within the normal range and continue to
monitor the patient
D. Initiate protective isolation and monitor for signs/symptoms of systemic
infection - ANSWERS-C. Document the result because it is within the normal range
and continue to monitor the patient
, The nurse is caring for a patient who just had a bone marrow aspiration. Which
outcome statement reflects the priority goal of care after the procedure?
A. Patient will not experience excessive bleeding
B. Patient's pain level will be 3/10 or less
C. Patient will not show signs/symptoms of infection
D. Patient will verbalize understanding of procedure results - ANSWERS-A. Patient
will not experience excessive bleeding
The nurse is assessing a patient who is newly diagnosed with anemia. Which
assessment findings are typical of this disorder? SATA
A. Dyspnea on exertion
B. Systolic hypertension
C. Intolerance to heat
D. Concave appearance of nails
E. Pallor of the ears
F. Headache - ANSWERS-A. Dyspnea on exertion
D. Concave appearance of nails
E. Pallor of the ears
F. Headache
A patient with sickle cell crisis is admitted to the hospital. Which questions does
the nurse ask the patient to elicit information about the cause of the current
crisis? SATA