41. A nurse in an emergency department is caring for a client who is to receive tissue plasminogen activator (tPA) for the treatment of an ischemic stroke. In which order should the nurse complete the following actions? (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)
Transfer the client to the CCU
Weigh the client
Administer the PA
Check for contraindications
The Correct Answer is D,B,C,A
Choice A rationale: Finally, the nurse should transfer the client to the CCU for close monitoring of vital signs, neurological status, and bleeding complications.
Choice B rationale: Then, the nurse should weigh the client to calculate the correct dose of tPA, which is based on body weight.
Choice C rationale: This comes after checking for the contraindications and weighing the client to determine the dose to be administered. The nurse should administer the tPA within 3 hours of symptom onset to dissolve the clot and restore blood flow to the brain.
Choice D rationale: The nurse should first check for contraindications to tPA, such as recent surgery, bleeding disorders, or uncontrolled hypertension.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice Arationale: A client with thrombocytopenia reporting a nosebleed may need intervention, but it is not an immediate concern unless severe bleeding is present.
Choice Brationale: A client with left-sided paralysis and slurred speech from a prior stroke may need attention, but their airway and oxygenation should take precedence.
Choice C rationale: A client with multiple sclerosis reporting ataxia and vertigo may need assessment and care, but their symptoms are not indicative of an immediate life-threatening situation.
Choice D rationale: A client with chronic obstructive pulmonary disease and an oxygen saturation of 89% requires immediate attention, as this indicates potential respiratory distress and hypoxemia.
Correct Answer is B
Explanation
Choice A rationale: There is no need to decrease the intake of fresh fruits or vegetables unless there are specific dietary restrictions given by the healthcare provider.
Choice B rationale: Limiting engaging in sport activities that can cause bruising is important because radiation therapy can make the skin more sensitive and prone to injury.
Choice C rationale: While some precautions may be necessary, decreasing time spent outdoors is not a general recommendation for all clients undergoing radiation therapy.
Choice D rationale: Limiting socializing in large crowds is not a standard precaution for clients undergoing radiation therapy.
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