A patient with ST-segment elevation in three contiguous electrocardiographic leads is admitted to the emergency department and diagnosed as having an ST-segment-elevation myocardial infarction. Which question should the nurse ask to determine whether the patient is a candidate for thrombolytic therapy?

Correct Answer: C

Rationale: The correct answer is C, “What time did your chest pain begin?” This question is crucial in determining if the patient is within the time window for thrombolytic therapy, which is typically within the first 12 hours of symptom onset. This therapy is most effective when administered early after symptom onset to dissolve the blood clot causing the myocardial infarction. Asking about the time of chest pain onset helps assess if the patient falls within this critical treatment window. Choice A, “Do you have any allergies?” is not directly relevant to the decision of thrombolytic therapy administration. Choice B, “Do you take aspirin on a daily basis?” is important for the patient’s medical history but does not directly impact the decision for thrombolytic therapy. Choice D, “Can you rate your chest pain using a 0 to 10 scale?” may provide information about the severity of pain but does not help in determining the eligibility for thrombolytic therapy based on the treatment

Correct Answer: D

Rationale: The correct answer is D: Reinforcement of teaching about the purpose of prescribed medications. This task can be safely delegated to an experienced LPN/LVN as it involves providing information that has already been taught by the RN. The LPN/LVN can reinforce the teaching without interpreting or altering the content. This task does not require critical thinking or assessment skills beyond the scope of practice for an LPN/LVN. A, evaluation of the patient's response to walking in the hallway, involves physical assessment and monitoring for any adverse signs or symptoms, which requires the RN's expertise. B, completion of the referral form for a home health nurse follow-up, involves coordination of care and decision-making, which falls under the RN's responsibility. C, education of the patient about the pathophysiology of heart disease, involves complex medical information and understanding, which is beyond the scope of practice for an LPN/LVN.

Correct Answer: A

Rationale: The correct answer is A: PTT (Partial Thromboplastin Time). PTT measures the effectiveness of heparin therapy by assessing the clotting time. Monitoring PTT helps ensure the therapeutic range of heparin is maintained to prevent clot formation. Incorrect Choices: B: HCT (Hematocrit) - measures the percentage of red blood cells in the blood, not specific to heparin monitoring. C: CBC (Complete Blood Count) - provides overall information about blood cells, not specific to heparin monitoring. D: PT (Prothrombin Time) - used to monitor Warfarin therapy, not heparin.

Correct Answer: C

Rationale: The correct answer is C: Return of the ST segment to baseline. This change indicates reperfusion of the myocardium, restoring blood flow and reducing ischemia. Widening of the QRS complex (A) suggests conduction abnormalities, not improved blood flow. Frequency of ectopic beats (B) can be a sign of ongoing myocardial damage. Presence of a significant Q wave (D) indicates a prior myocardial infarction, not immediate improvement in blood flow. Therefore, focusing on the return of the ST segment to baseline is crucial for assessing myocardial reperfusion.

Correct Answer: C

Rationale: Rationale: During a tet spell in tetralogy of Fallot, there is a sudden decrease in pulmonary blood flow, leading to cyanosis and hypoxia. Meperidine (Demerol) is the drug of choice due to its rapid onset and ability to increase systemic vascular resistance, improving blood flow to the lungs. Propranolol (A) may worsen the cyanosis by decreasing pulmonary blood flow. Morphine (B) and Furosemide (D) do not address the underlying problem of decreased pulmonary blood flow and are not indicated during a tet spell.